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S1405

Failure to Ensure Timely Employee Health Examinations for New Hires

Elizabeth, New Jersey Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that newly hired employees received a required health examination by a physician, advanced practice nurse, or New Jersey licensed physician assistant within two weeks prior to employment or upon employment, or within thirty days if a registered nurse assessment was completed upon hire. During a review of 10 randomly selected newly hired employee files, it was found that 6 did not have documentation of a completed physical examination as required by regulation. Specifically, one LPN had no pre-employment health screen or documentation of a physical, and other staff had only partial or incomplete health reports. Interviews with the Director of Nursing (DON) confirmed that the facility's process was to have new hires receive a physical 1 to 2 weeks prior to starting work, typically performed by the facility's medical director. Upon review of the files, the DON acknowledged the missing or incomplete documentation and was unable to provide additional information to demonstrate compliance. The facility's policy also required a health review and physical examination for all new employees, but the records reviewed did not consistently meet these requirements.

Plan Of Correction

Element #1. On 6/5/2025 The facility Human Resource Manager (HR), Administrator and Director of Nursing began an audit on all new hire within the last (1) year to schedule date for each new hire to complete a Register Nurse (RN) assessment or physical examination. The Facility Administrator in-serviced on 6/6/2025 the director of nursing to follow the facilitys policy on completing an Registered Nurse assessment upon prior to hire date and schedule health physician exam with the facilitys medical director for all new employees in the required time frame. Element #2. All residents have the potential to be affected by this deficient practice by not completing registered nursing assessment or physician assessment within the required time frame. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting.

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