Unverified Agency CNA Identity and Certification Leading to Unqualified Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies and valid certification, specifically by not having a policy or process to verify the identity and credentials of agency staff working as CNAs. The facility’s CNA job description required a current CNA certification in accordance with Illinois law. However, on one occasion, an individual (V28) worked an entire scheduled CNA shift under another person’s identity (V20) obtained through a contracted staffing agency. The administrator (V1) reported to law enforcement (V29) that V28 was operating under the false name V20 while working as a CNA and that the only documentation V1 had seen was the staffing agency profile for V20. V1 later checked the registry under V28’s real name and discovered that V28 was not listed as a CNA. During the incident, V28 arrived for a scheduled shift that was assigned to V20 and used V20’s name to gain access to the EMR and work as a CNA from 6:00 a.m. until an altercation occurred around 5:00 p.m. Another staff member (V19) reported that V28 had been working that full shift, and V20 later stated that they had not picked up any shifts at the facility. An email from the Health Care Workers Registry confirmed that V28 did not have CNA certification and was not eligible to be employed as a CNA, though eligible to work in a non‑CNA capacity. The facility census at the time was 39 residents, and the lack of a policy to verify agency staff identity and certification resulted in an uncertified individual providing CNA-level care to residents under another person’s credentials.
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