Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening five employees for employment. The regulatory requirements under §§483.12(a)(3) and 483.12(b)(1) mandate that the facility must have written procedures for screening prospective employees, which include reviewing employment history, obtaining information from former employers, and checking documentation of status and any disciplinary actions from licensing or registration boards. However, the facility's Resident Abuse policy, last reviewed in December 2023, required obtaining references from current or previous employers, which was not adhered to. A review of employee personnel files revealed that for five employees, including two LPNs, a Nurse Aide, a Dietary Aide, and the DON, there was no documentation showing that the facility had contacted any former employers to verify past employment. Interviews with the Administrator confirmed that there was no evidence of previous employers being contacted for information regarding the employees' past work history. This lack of verification indicates a failure to follow the facility's own abuse prohibition policy.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the identified individuals are established employees. For all potential employment candidates, the Human Resources Coordinator will contact former employers for information regarding former employment history and professional references for feedback regarding affirmation of employment. The Human Resources Coordinator will create a spreadsheet to track all new candidates and monitor the receipt of personal and professional employment references monthly. The Human Resources Coordinator will report monthly at QAPI x3.