Failure to Implement Identified Offenders Program and Timely Criminal Background Checks
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures related to the Identified Offenders Program (IOP), criminal background checks, and fingerprinting for multiple residents. Surveyors reviewed records for 10 residents and found that required Criminal History Information Response Process (CHIRP) checks were not consistently completed within 24 hours of admission as required by facility policy. For several residents, including those with documented criminal histories such as burglary, theft, domestic battery, aggravated arson, and sexual offenses, CHIRP reports were either delayed or missing within the required timeframe. In addition, when CHIRP results showed “hits” and arrest charges that triggered the need for fingerprinting under the facility’s IOP process, the facility failed to obtain fingerprint orders within 72 hours and, in many cases, could not produce any documentation that fingerprinting was ever completed. For some residents, fingerprints were obtained weeks or more than a year after admission, and for others, staff were unable to locate any fingerprint documentation at all. The Social Services Director (V4) repeatedly stated that staff were unable to find when fingerprints were ordered and that they could not locate confirmation that certain residents had been fingerprinted. The facility’s written Abuse Prevention Policy and Resident Rights Guideline require pre-admission and post-admission criminal history checks, including CHIRP, sex offender registry checks, and fingerprinting when indicated, to help ensure a safe environment and residents’ freedom from abuse, neglect, exploitation, and misappropriation of property. Despite these policies, the facility did not follow the required timelines for CHIRP completion, did not consistently obtain or document fingerprinting after CHIRP hits, and did not maintain the necessary IOP documentation for all 10 reviewed residents. The Social Services Director indicated that the prior Social Services Director had been responsible for IOP tasks and was unsure why the IOP requirements had not been completed as required.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.