Failure to Verify Staff Licensure Prior to Hire
Penalty
Summary
The facility failed to ensure that residents were protected from the potential for abuse by not verifying the professional licensure status of two employees prior to their hire. Specifically, the personnel file for a Certified Nursing Assistant (CNA) showed that certification verification was completed after the employee's hire date. Similarly, the personnel file for a Licensed Practical Nurse (LPN) indicated that license verification with the state licensing board was also completed after the employee's hire date. These actions were not in accordance with the facility's own policy, which requires verification of active licensure or certification prior to employment. During interviews, it was revealed that Human Resources is responsible for completing a checklist to ensure all required items, including license verification, are completed and then forwarding this information to the hiring manager. However, the hiring manager discards information not entered into the employee's file, and the facility was unable to locate evidence that licensure verification was completed before the employees began working. This failure to verify licensure prior to hire was identified through review of facility policy, personnel files, and staff interviews.
Plan Of Correction
F 0606 1. No individual resident has been identified. Employee 3 and Employee 4 license verification were completed on 12/9/25. 2. An audit of current employee files of those with Licenses or Certifications was completed on 12/16/2025 to validate employee licenses or certifications are in good standing, and employees are fit for service. 3. Re-education to HR Payroll Benefit Coordinator, Receptionist, and Nursing Leadership on the facility policy "Admin Freedom from Abuse Policy" will be provided by the Executive Director. The HR Payroll Benefit Coordinator or designee will verify licensure/certification and will print the verification prior to offering any position. This will be maintained in the HR office in the employee file. 4. The Executive Director, or designee will conduct weekly audits x 12 weeks of potential new hires to validate license/certification verification has occurred and is in employee file. Findings of audits will be analyzed to identify/track trends or patterns and will be reported monthly to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.