Uncertified Hospitality Aides Providing Direct Care Beyond 4 Months Without Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s use of caregiver hospitality aides as nurse aides beyond four months of employment without completion of a nurse aide training and competency evaluation program, and without competency check-offs. Record review showed that one caregiver hospitality aide was hired on 08/06/2025 and another on 07/30/2025, both working full time, with employability status checks indicating neither had CNA certification. The facility’s job description for hospitality aides, dated 03/2020, listed a range of non-nursing, non-direct care duties under the supervision of licensed nursing personnel, but also included tasks such as providing personal care (e.g., combing hair, washing face and hands) and staying with residents while in the bathroom. During interviews, one caregiver hospitality aide reported performing incontinent care without a CNA or nurse at bedside and stated she had taken courses but had not taken the certification test. Another caregiver hospitality aide stated he performed sit-to-stand transfers with residents and, when the only CNA on night shift was busy, he would obtain help from another hospitality aide to perform incontinent care and transfers; he reported having been shown how to do these tasks at another facility but confirmed he was not certified. The DON stated that hospitality aides did not have competency check-off lists, were not supposed to perform peri-care or transfers, and were not to do anything involving touching residents because they were not certified. The DON and the administrator both acknowledged there were no competency check-off lists for caregiver hospitality aides, that uncertified staff were not supposed to provide direct care unless paired with a nurse or CNA, and that staff performing direct care should have certification within four months of hire, identifying this as a system failure between nurses and staff with potential for residents to receive improper care from uncertified aides.
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