Incomplete Criminal History Record Check Form
Penalty
Summary
The facility failed to ensure that the Acknowledgement and Consent form for Fingerprinting and Disclosure of Criminal History Record Information (Form 102) was accurately completed and signed by the Authorized Person before submitting a request for a Criminal History Record Check. This deficiency was identified in the record of an employee hired as a Certified Nursing Assistant. The form, which is a requirement for all direct caregivers and staff with access to residents or their property, was incomplete as Section #3 was neither signed nor dated by the Authorized Person. The Human Resources Director, who was responsible for completing and signing the form, admitted during an interview that the oversight occurred because the employee was hired through a staffing agency. The Director acknowledged that the form was signed by the employee in May 2023, but the request for the background check was not submitted until September 2024. The Administrator confirmed that it is the responsibility of the Authorized Person to ensure the form is correctly filled out and signed, indicating that the oversight was an error in the facility's process.
Plan Of Correction
Plan of Correction: Approved January 30, 2025 Element 1: The employee is no longer active. Employee has been terminated on CHRC. Facility is now in compliance. Element 2: All residents had potential to be affected by the deficient practice. Element 3: The policy for CHRC / FINGERPRINTING – NY was reviewed and no revisions were necessary. The CHRC authorized Users were inserviced on CHRC / FINGERPRINTING – NY policy. An audit tool was developed. Weekly rounds x4, Monthly x3 to ensure proper CHRC process is performed. Element 4: Audit to be done by Administrator/designee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA committee monthly x3. Responsible party Administrator/designee.