Failure to Obtain Criminal History Record Check Forms
Summary
The facility failed to obtain a signed Acknowledgment and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form, known as Criminal History Record Check form 102, for two out of five employees reviewed during the recertification survey. The facility's policy, revised in November 2018, requires the Director of Human Resources or a designee to obtain this signed authorization from prospective employees. However, there was no documented evidence that Employees #28 and #29 had completed and signed the required form. During an interview, the Human Resources Director confirmed that the forms for these employees were not completed and acknowledged gaps in the policy that needed addressing to prevent future occurrences.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Form 102 Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form completed for employees #28 & #29. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit employee files for form 102 for CHRC. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education to Human Resources on CHRC regulation/license. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing of new hires and current employees for form 102 to occur x10/month for 3 months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Human Resources.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.