Unlicensed Personnel Performed LPN Duties Without Verification
Summary
The facility failed to ensure that personnel had the appropriate state licensure to provide care and services to residents. This deficiency was identified when S5, an unlicensed personnel, worked in the capacity of an LPN and performed nursing tasks without a Louisiana nursing license. The issue was discovered after S5 had been providing care and services to residents from November 20, 2024, until January 24, 2025, affecting 87 residents. The facility's Professional Licensure Verification Policy required that all employees with a professional license be verified upon hire and as required through the appropriate licensure board. However, S5's status was changed from a Certified Nurse Aide (CNA) to an LPN without verifying the necessary licensure. S5 signed the Licensed Staff Job Description, and the facility documentation confirmed that S5 provided care in the capacity of an LPN without having passed the National Council Licensure Examination for Practical Nurses (NCLEX-PN) in Louisiana. Interviews revealed that the Team Member Specialist (TMS) was responsible for verifying licensure but failed to do so before changing S5's status. The Director of Nursing (DON) allowed S5 to start training as an LPN without verifying licensure, and the Administrator directed the status change and allowed S5 to perform LPN duties without ensuring a valid license. This oversight led to an immediate jeopardy situation, as there was a likelihood of serious injury, harm, or death due to having unlicensed personnel providing nursing services.
Removal Plan
- Unlicensed Personnel was suspended and terminated.
- Administrator, DON, and TMS were in-serviced on licensure verification and reporting wrongdoing.
- Cognitive resident interviews were completed by Regional RN regarding any medication administration concerns or other nursing concerns.
- Full facility wide audit started on all nurses to ensure active license in place.
- In-service on reporting wrongdoing was completed by Administrator, DON, TMS, and staff.
- Audits were completed of resident's electronic medical records documentation who received care from Unlicensed Personnel while Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
- TMS to verify licensure prior to nurse hired or role change if currently working. DON would be provided with a copy for double verification at the facility level.
- Corporate Compliance Officer to audit weekly for compliance for three months and annually.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
CNA A worked multiple CNA shifts and performed direct care tasks while her nurse aide certification was expired. Records showed the facility had notice of the expiration through EMR review and corporate HR license lists, yet CNA A still worked on the floor for 83.88 hours. In interview, CNA A said she continued giving showers, assisting with ADLs, and charting under other aides’ logins, while HR, the DON, and the ADM gave conflicting accounts about whether expired CNAs could still work.
Expired CNA Certification: The facility failed to ensure a CNA’s certification was current before allowing her to provide resident care. CNA A worked full-time for 8 days with an expired certification, and interviews showed HR was unaware of the expiration, there was no system to track certification dates, and the CNA did not know her certification had lapsed.
An LPN worked multiple shifts after her nursing license had expired, and the facility did not identify the lapse. HR, the DON, and the Administrator each stated they were unaware the license was no longer current, and records showed the LPN continued working during the expired period before later being removed from payroll.
The facility failed to employ an RN in accordance with MD law when the DON was found to have a valid compact RN license from FL but no verifiable MD license on file or through the MBON website. The HR Director stated she verified licenses through MBON and believed a compact RN license was sufficient, while also confirming the DON was the only staff member working with a FL compact license and an expired LPN license. The DON stated she claimed dual residency in MD and FL and would get the MD license, and the NHA acknowledged the concern.
Unlicensed staff used the Social Worker title for two residents. A staff member authored social service notes as a Social Worker, spoke with a resident and family about discharge and emotional distress, and discussed Medicaid and discharge planning with another cognitively intact resident. Interviews and records showed the staff member had no SW license, while another employee was identified as a Social Work Designee.
Administrator License Not Current: The facility governing body failed to ensure the Administrator had a current Ohio license. The Administrator confirmed he was the acting Administrator and later acknowledged his license was not current, stating he was having technical difficulties renewing it. BELTSS records showed the license had an issue date of 04/20/11 and an expiration date of 07/01/26.
CNA Worked With Expired Certification
Penalty
Summary
The facility failed to ensure that CNA A maintained an active nurse aide certification before performing CNA duties. Review of the facility’s initial EMR check showed CNA A was employable even though her nurse aide certification had already expired, and the Texas HHS TULIP nurse aide search showed her most recent nurse aide license issuance and initial certification dates. A company-wide staff list from corporate HR also identified CNA A and listed her nurse aide license expiration date. Timecard records showed CNA A worked multiple shifts while her certification was expired, including a total of 83.88 hours between the dates reviewed. The records reflected shifts worked on several nights, and CNA A stated in interview that her CNA license had lapsed, but the facility allowed her to continue working on the floor as a CNA until it was reinstated. She stated she was performing CNA tasks such as giving showers, assisting with ADLs, and documenting care in the electronic system under other aides’ logins because she had not yet been added to the system. Interviews with HR, the DON, and the ADM showed the facility relied on HR and corporate spreadsheets to monitor expiring licenses, but staff were unclear about whether CNAs could work after expiration. HR stated she believed there was a 30-day grace period, while the DON said she was not familiar with such a rule and was not aware CNA A had worked on the floor with an expired license. The ADM stated HR managed licensure monitoring and that the facility’s policy required current licensure to be verified and maintained, with copies retained in company files.
Expired CNA Certification
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 4 CNAs reviewed. CNA A’s certification had expired, yet she continued to work in the facility providing resident care on a full-time basis for 8 days while her certification was not current. Record review showed CNA A’s certification expiration date and the time sheets and staff schedule showed she worked multiple shifts during the period her certification was expired. During interviews, the Human Resources Director stated she was not aware CNA A’s certification had expired and said there was not a system in place to track nurse aide certification expiration. The Staffing Coordinator stated she became aware of the expired certification during the investigation and removed CNA A from the schedule until the certification was renewed. CNA A stated she was unaware her certification had expired. The Administrator stated the HR Director was responsible for checking nurse aide certifications monthly after date of hire, and the facility policy required Human Resources to verify professional licenses, certifications, and education.
LPN Worked Without a Current License
Penalty
Summary
The facility failed to ensure that an LPN maintained current credentials, as LPN #1’s nursing license had expired and was not renewed. According to Maryland Department of Health records, the license expired and LPN #1 continued working in the facility during the lapse. Time card and employee punch reports showed LPN #1 worked multiple shifts in the facility during the period the license was expired, and the HR Director acknowledged that LPN #1 worked 136 shifts without a current nursing license. The Payroll Change Notice showed LPN #1 was later removed from the payroll effective [DATE], and the Payroll Change Form indicated LPN #1 told the facility she was retiring. During interviews, LPN #1 stated she did not know her license had lapsed, the HR Director stated she was not aware the license had expired, the DON stated she relied on HR to ensure licenses were current, and the Administrator stated he was not aware LPN #1 worked without a current nursing license.
RN Licensure Not Verified for DON
Penalty
Summary
The facility failed to employ an RN in accordance with Maryland State law for one employee file reviewed during the annual survey. During review of complaint #3055819, surveyors found that Staff #2, the DON, held a valid compact RN license from Florida and resided in Maryland, but the surveyor could not verify a Maryland license through the MBON website, and no copy of a Maryland license was on file. The complaint alleged that the DON's RN license was from Florida and that her Maryland LPN license was inactive with the Maryland Board of Nursing. During the survey, the HR Director stated that nurse licenses are verified through the MBON website and that staff with multistate RN licenses are hired if they have a compact license. She also stated that she was not aware that in Maryland a nurse is required to have an active license in the state of primary residence. When asked for a list of nurses with compact RN licenses, the HR Director provided a list showing that the DON was the only staff member working in the facility with a Florida compact license and an expired LPN license. The DON was informed that Maryland state law requires an MD license if the nurse physically resides in Maryland and claims Maryland on the W-2, and she stated that she claimed dual residency in Maryland and Florida and would get the MD license. The NHA was present and acknowledged the concern.
Unlicensed staff used the Social Worker title
Penalty
Summary
The facility failed to ensure that staff who identified themselves as Social Workers had the required credentials under state law for two residents reviewed. A complaint intake alleged that Staff Member F incorrectly and fraudulently identified herself as a licensed social worker to professionals, families, and residents, despite not having a social work degree or license. The report also cited Michigan law stating that only a licensed bachelor's or master's social worker may use the title social worker. For one resident admitted for a hospice respite stay with diagnoses including unspecified severe protein-calorie malnutrition and hypertension, late-entry Social Service Progress Notes were authored by Staff Member F and listed her position as Social Worker. Those notes documented that she spoke with the resident about wanting to return home, informed the resident of the planned discharge date, and spoke with the family. An email from a family member also stated that the resident received a call from the facility, was crying and emotionally distressed, and that a staff Social Worker identified herself during the call. For a second resident admitted with diagnoses including unspecified cirrhosis of the liver and neuromuscular dysfunction of the bladder, the admission BIMS score was 15 out of 15, indicating cognitive intactness. The resident described interactions with the Social Worker regarding money, payments, and help applying for Medicaid. Social Service Progress Notes authored by Staff Member F again listed her position as Social Worker and documented discussions about discharge planning and Medicaid documentation. During interviews, Staff Member F identified herself as a Social Worker, stated she did not have a Social Work license, and said she had business cards with the title Social Worker. Her personnel file and business card reflected the title Social Worker, while another employee was identified as a Social Work Designee.
Administrator License Not Current
Penalty
Summary
The facility governing body failed to ensure that the Administrator, who was responsible for management of the facility, had a current Ohio license. During interview, the Administrator confirmed he was the acting Administrator for the facility. Review of the BELTSS system showed the Administrator’s license had an issue date of 04/20/11 and an expiration date of 07/01/26. On interview, the Administrator verified he was the Administrator of record and acknowledged that his license was not current, stating he was having technical difficulties when trying to renew it.
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