Staff Licensing and Registration Deficiency
Penalty
Summary
The facility failed to ensure that staff were licensed and registered in accordance with State laws for three of the eleven personnel files reviewed. Employee E21, a registered nurse, was found to be working with an expired nursing license, which had expired on October 31, 2024. The facility discovered this lapse on December 18, 2024, and subsequently provided education to Employee E21 regarding the policy that mandates maintaining an active nursing license at all times. Employee E21 reactivated her nursing license on December 20, 2024. Additionally, the facility conducted an audit of all employees with nursing licenses and nurse aide registries, which revealed that Employees E17 and E16, both nurse aides, were not included in the audit. Further review showed that neither employee was enrolled in the Pennsylvania nurse aide registry, a requirement for employment in a nursing care facility receiving Medicare or Medicaid reimbursement. Employee E17 was hired on October 22, 2024, and Employee E16 on November 19, 2024, both having completed a nurse aide training course prior to their hiring. However, they were not registered to work as nurse aides in Pennsylvania, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Employee E21 provided no direct care and caused no harm to residents. Employee E17 and E16 are no longer employed at the facility. 2. Employee E21 was educated on his responsibility to ensure his license is renewed timely and active. 3. NPE or designee to educate licensed nursing staff on the importance of timely license renewal. 4. NPE or designee will conduct an initial audit of licensed nursing staff then monthly audits x 3 months to ensure compliance. 5. NHA or designee to review results of these audits at the monthly QAPI meeting x 3 months.