Failure to Monitor and Enforce Staff Background Screening Eligibility
Penalty
Summary
The facility failed to ensure that all staff were eligible for employment based on background screening, specifically regarding the Director of Facilities. Review of the facility's policies and procedures indicated that individuals with a 'Not Eligible' status on background checks should not be hired or allowed to continue employment. However, the Director of Facilities was listed as active in the facility's emergency management system despite having a 'Not Eligible' status effective as of July 2025, as shown in the AHCA Clearinghouse documentation. The Facility Administrator and Human Resources staff were unaware of this status change and confirmed there was no process in place to monitor background eligibility for staff not included on the skilled nursing roster. Interviews with facility leadership revealed that campus-wide staff, such as the Director of Facilities, were not included on the skilled nursing roster in the AHCA Clearinghouse, and there was no established method to track changes in their eligibility status. As a result, an individual who was not eligible for employment due to background screening was allowed continued access to the building and proximity to residents, contrary to facility policy and procedure.