Failure to Verify Nurse Aide Certification Status
Penalty
Summary
The facility failed to verify the nurse aide certification status of Employee E8, which led to the individual working with a revoked certification. Employee E8 was initially hired with a valid nurse aide certificate, and the facility last verified this certification in July 2023. However, the certification was revoked in July 2024 due to a substantiated finding from a different facility, which the facility did not become aware of until October 2024 during a routine audit. The Human Services Director, Employee E9, discovered the revocation while auditing staff licenses. Upon confronting Employee E8, it was confirmed that the certification was indeed revoked, and Employee E8 was aware of this. Despite this, Employee E8 continued to work until the discovery was made. The facility's failure to check the quarterly annotation list, which would have indicated the revocation, contributed to this oversight. Interviews with the Nursing Home Administrator and the HR Director revealed that the facility was not aware of the quarterly annotation list that could have alerted them to the revocation. The facility only became aware of the revocation after conducting an audit and subsequently suspended and terminated Employee E8. The lack of awareness and failure to regularly verify the certification status of their staff led to this deficiency.
Plan Of Correction
Step 1 Protocol to immediately check the annotation list was initiated on 10/24/24. Moving forward the facility will review the annotation list quarterly to ensure that no current staff members are listed. Step 2 HR director will complete an audit of all current employee files to ensure that no current employees are not listed in the most recent annotation list. Step 3 HR personnel educated on the requirement to check the annotation list quarterly to ensure that no current employees are listed in the annotation list. Step 4 HR director/ designee will audit new hires weekly x4 than monthly to ensure that new hires are not listed on the annotation list.