§483.35(d)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-
(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.
§483.35(d)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.
§483.35(d)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
|
Observations:
Based on a review of employee files and staff interviews, it was determined that the facility failed to ensure that certified nurse aides received registry verification following the expiration of nurse aide registration for one of four nurse aides (Employees E1).
Findings include:
Review of the Event Reporting System report submitted to the Department of Health on 1/31/24, indicated Nurse Aide (NA), Employee E1's registration was noted to be expired. It stated Nurse Aide, Employee E1 was hired on 11/7/22. Her certification expired on 1/30/23. The original issue date was 1/31/11. NA, Employee E1 was working the weekend program. She was notified and immediately removed from the schedule and given the contact information for certification renewal.
Review of Nurse Aide, Employee E1's personnel record indicated she was hired on 11/7/22, and revealed a Pennsylvania Department of Health Nurse Aide Registration for Employee E1, effective 1/30/21, and expired on 1/30/23.
Review of facility's "Daily Staffing Sheet" dated 1/21/24, indicated NA, Employee E1 worked as a NA on the Daylight and Evening shift.
During an interview on 2/16/24, at 1:38 p.m. Licensed Practical Nurse, Employee E2 confirmed NA, Employee E1 nurse aide license expired on 1/30/23, and has worked in the facility with an inactive license through 1/21/24.
During an interview on 2/16/24, at 2:05 a.m., the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that NA's received registry verification following the expiration of NA registration for one of four nurse aides (Employee E1).
28 Pa. Code 211.12(c) Nursing services
| | Plan of Correction - To be completed: 03/22/2024
F729
Employee 1 was suspended immediately upon discovery of expiration date having passed on her nurse aide registration. Employee 1 was able to renew her nurse aide registration immediately following the discovery.
A house wide audit was completed with no other nurse aide registrations noted as expired.
Credentials for nurse aid registration will be completed upon hire and annually thereafter.
Human Relations and Staffing Coordinator will be educated on F729 with a focus on ensuring that certified nurse aides' registration is valid upon hire and renewed as per Pennsylvania standards.
Audits will be completed bi-weekly by the Administrator/designee on new staff and any staff due for their annual review to ensure a valid nurse aid registration is held by the individual. The Administrator shall ensure compliance.
|
|
