Latta Road Nursing Home East
January 17, 2025 Complaint Survey

Standard Health Citations

FF15 483.35(d)(4)-(6):NURSE AIDE REGISTRY VERIFICATION, RETRAINING

REGULATION: 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (NY 033), the facility did not ensure that one (Certified Nursing Assistant (Aide) #4) of three Certified Nursing Assistants' certifications were current during the employees' employment at the facility. Specifically, the New York State Nurse Aide Registry Verification Report for Certified Nursing Assistant #4 documented their certification had lapsed (expired) effective [DATE] and not been renewed. Certified Nursing Assistant #4 continued to work in the facility with direct resident care for a period of time without a valid certification from the New York State Nurse Aide Registry (Prometric). This is evidenced by the following: The facility policy Certified Nursing Assistant (CNA) Certificate Renewal, dated [DATE], included all Certified Nursing Assistants recertification would be monitored by the Director of Nursing on a monthly basis, and the certificate renewal process would start in the beginning of the month in which the certificate was due to expire. During the first week of every month, all recertification paperwork would be provided to the Business Office Manager and sent to the State of New York. Review of Certified Nursing Assistant #4's certification #NY 1544E on [DATE] revealed an expiration date of ,[DATE]/ 2024. Review of the New York State Nurse Aide Registry on [DATE] revealed Certified Nursing Assistant #4's certification remained lapsed effective ,[DATE]/ 2024. Review of a Nursing Assistant Registry Renewal Form completed for Certified Nursing Aide #4 revealed a renewal form had been completed by the previous Director of Nursing, dated ,[DATE]/ 2024. Review of facility billing records for shifts worked from [DATE] to [DATE] revealed Certified Nursing Assistant #4 continued to work in the facility providing direct resident care without a valid certification from the New York State Nurse Aide Registry. During an interview on [DATE] at 11:20 AM, Business Office Manager #1 stated the process for ensuring certifications were up to date was run by the Director of Nursing, who checked monthly to see who needed recertification. Business Office Manager #1 stated the renewal form should be completed and sent with a check to Prometric (New York State Nurse Aide Registry). Business Office Manager #1 stated after about three months, a new copy of the certified nursing aide's certification would be sent to the employee, who then provided a copy to the facility. Business Office Manager #1 stated since the COVID-19 pandemic, there had been a three- to six-month lapse (grace) period (certified nursing assistants could still work during that period) from the New York State Nurse Aide Registry. During a telephone interview on [DATE] at 3:22 PM, Prometric Customer Service Representative #1 stated the facility (employer) should fill out the certification renewal form which included (but not limited to) the facility's code and the time the certified nursing assistant worked. Prometric Customer Service Representative #1 stated once the renewal form was received (via mail), it would take two to three weeks to process, unless more information was needed. Prometric Customer Service Representative #1 stated the certified nursing assistant's new certificate would be emailed to either the employee's home address or the facility, depending what information was in the system. Prometric Customer Service Representative #1 stated a certificate would show as lapsed if past the expiration date and if the renewal form was in process. Prometric Customer Service Representative #1 stated that any grace period allowing a certified nursing assistant to work while their certificate was being processed after the expiration date would be at the discretion of the employer (facility). Prometric Customer Service Representative #1 stated a certificate would be considered expired (if past expiration date) until everything was processed in their system. Prometric Customer Service Representative #1 stated Certified Nursing Assistant #4's certificate had lapsed on [DATE] and the certificate was still pending because of an employer code error and the employer's title was left blank. During an interview on [DATE] at 4:48 PM with the Director of Nursing, the Nurse Educator, the Business Office Manager #1, the Social Worker, and the Administrator (via telephone), the Director of Nursing stated at the beginning of each month they check (certificates due for renewal) and pass along to the business office, so they could send the check. Business Office Manager #1 stated if a certified nursing assistant's certificate had expired and they had not received the active certificate, the employee had 90 days (during which they could work). Business Officer Manager #1 stated Prometric stated they had 90 days but could not recall who told them this. Business Officer Manager #1 stated there is no follow-up with Prometric during those 90 days, and that Prometric is behind (with processing and sending certificates). Business Office Manager #1 stated if it is past the 90 days and the certified nursing aide's active certificate is not received, they would take the employee off the schedule. Several attempts made to interview Certified Nursing Aide #4 were unsuccessful. 415. 26(c)(3)

Plan of Correction: ApprovedFebruary 7, 2025

1. CNA #4 was terminated from the facility effective 10/15/ 2024. 2. An audit of all CNAs certification at the facility was completed and reviewed. The were no other CNAs that did not have an active C.N.A certificate. Completed: 1/2/2025 3. The facility has reviewed the facility policy on C.N.A renewal and there has been no changes. A spreadsheet is sent to this Director of Nursing and the Administrator that automatically populates notification 45 day prior to the expiration date. 4. All renewed C.N.As will be reported to the Quality assurance team for 3 months then quarterly thereafter to ensure that all Certification renewals are completed timely Responsible party: Business office