Personnel Record Deficiency for RN Employee
Summary
The facility failed to ensure that personnel records for Registered Nurse (RN) Employee E2 included essential documentation such as a job description, educational background, employment history, and a reference check. This deficiency was identified during a review of the facility's policy, employee personnel records, and staff interviews. The facility's policy, "Safety-01 Abuse, Neglect, Exploitation general policy," mandates that reasonable efforts be made to obtain personal and professional reference information before an employee's first day of employment, with documentation of these attempts. However, RN Employee E2, who was hired on 9/3/24 and began working independently by 9/17/24, did not have the required documentation in her personnel file. The Nursing Home Administrator confirmed this oversight during an interview.
Plan Of Correction
The personnel record for registered nurse (E-2) has been updated to include the employee's job description, educational background, employment history and a reference check. Human Resources and the In-service director have been re-educated on the importance of ensuring that all pre-employment documentation including but not limited to the employee's job description, educational background, employment history and a reference check must be obtained prior to the first day of employment. All new hire paperwork including the employee's job description, educational background, employment history and a reference check will be audited every two weeks for two months by the administrator or designee to ensure all documentation is completed prior to their first day of employment. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Penalty
Surveyors found that the facility did not maintain documented job descriptions in the personnel files of a nurse aide, an activities aide, and a dietary aide, as required by policy. This was confirmed by the administrator during the review.
The facility failed to maintain complete personnel records by not including signed job descriptions for four employees, including two NAs and two RNs. This deficiency was confirmed during an interview with the Nursing Home Administrator.
The facility failed to include job descriptions in the personnel files of an LPN and three RNs. This was confirmed during a review of employee records and staff interviews, where the Regional HR Employee could not provide the required documentation.
Missing Job Descriptions in Employee Personnel Files
Penalty
Summary
The facility failed to ensure that the personnel records for three employees, specifically a nurse aide, an activities aide, and a dietary aide, contained documented evidence of their job descriptions. Review of the personnel files for these employees, all hired in 2025, revealed that none included a written job description outlining the duties, responsibilities, and qualifications for their respective roles. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility could not produce the required documentation for these employees.
Plan Of Correction
Employee #5, #7, and #8 have signed job descriptions. To identify like individuals that have the potential to be affected, NHA/designee will audit new hires in the last 14 days to ensure job descriptions are signed by the employee. To prevent this from recurring, Human Resources will be educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee will audit new personnel files weekly for the first four weeks, then monthly for two months, to ensure personnel files contain the signed job description. Results will be reported to QAPI for recommendations and follow-up.
Incomplete Personnel Records Due to Missing Signed Job Descriptions
Penalty
Summary
The facility was found to be deficient in maintaining complete personnel records, as evidenced by the absence of signed job descriptions for four out of five employee files reviewed. The employees in question included two Nurse Aides and two Registered Nurses. The review of personnel files took place on January 24, 2025, and revealed that the files for these employees, who were hired on January 13, 2025, and December 9, 2024, did not contain the required signed job descriptions. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the oversight in ensuring that personnel records were complete and included signed job descriptions for the staff members involved.
Plan Of Correction
All personal files were reviewed by HR to ensure completion of job descriptions with a signature. Personal files will be reviewed weekly by HR and Administrator for 6 weeks, then monthly. All results to be reviewed through QAPI for further recommendation. 2/25/25 All personal files were reviewed by HR to ensure completion of job descriptions with staff signatures. Personal files will be reviewed weekly by HR and the Administrator for 6 weeks, then monthly. All newly hired staff to sign off on their job description during the "hiring process." All results to be reviewed through QAPI for further recommendations.
Missing Job Descriptions in Personnel Files
Penalty
Summary
The facility failed to ensure that personnel records included a copy of the employee's job description for four out of five personnel files reviewed. This deficiency was identified during a review of employee personnel records and staff interviews. Specifically, the personnel files of a Licensed Practical Nurse and three Registered Nurses did not contain documented evidence of their job descriptions. The Regional Human Resource Employee was unable to provide the job descriptions upon request. The Nursing Home Administrator confirmed the absence of job descriptions in the personnel records during an interview.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. Job descriptions will be added to Licensed Practical Nurse Employee 1, Registered Nurse Employee 5, and Registered Nurse E6's employee file. 2. The Human Resource Director/designee will audit new hire employee files from the past three months to ensure the employee's job description is in the file. 3. The Human Resource Director will be reeducated by the Nursing Home Administrator/designee on the ensuring a job description is in the employee file. 4. The Nursing Home Administrator/designee will audit new hires weekly for three weeks and monthly for three months to ensure files have an employee job description. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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