Failure to Ensure Required Annual In‑Service Hours for a CNA
Penalty
Summary
The facility failed to ensure that one of five reviewed CNAs, identified as CNA AA, received the required 12 hours of annual in‑service training, as documentation showed only 7.75 hours of education completed for 2024. On the morning of 2/11/26, surveyors requested in‑service/education training hour records for five CNAs (Y, Z, AA, BB, and CC), and the records provided demonstrated the shortfall for CNA AA. During an interview later that day, the Infection Preventionist/Staff Development nurse (Nurse C), who had been in the staff development role since mid‑October 2025, stated they were responsible for reconciling education hours and suggested there might have been an electronic system issue, but confirmed that the documentation provided was all they could locate. Nurse C reported there was corporate oversight but could not explain why the facility had not identified CNA AA’s lack of required education/training, and no additional documentation was produced by survey exit. The facility’s own policy, “In‑Service Tracking” dated 2/4/2024, states that the Administrator will appoint a Staff Development Nurse or HR representative to track in‑service education and that department managers will assure timely completion of student in‑service education.
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