Failure to Maintain Required Background and Registry Checks for Staff
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain required screening policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Surveyors found that the facility did not have complete or current Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) checks, and did not complete required criminal background checks for multiple staff members. These failures occurred despite written facility policies requiring criminal history checks and registry screenings prior to hire, upon rehire, and annually thereafter, in accordance with Texas Health and Safety Code, Chapter 250, and the facility’s HR Personnel Handbook. During interviews and record reviews with the HR Coordinator and administrator, surveyors identified missing or incomplete documentation for 7 of 10 employees reviewed for EMR/NAR screenings and 2 of 10 employees reviewed for criminal checks. For RN O, rehired on 02/23/24, the HR Coordinator could not locate a criminal background check in the personnel file and found only one EMR/NAR check dated 01/20/25, with no evidence of annual follow-up. For CNA P, CNA L, LVN D, LVN N, and the DON, the most recent EMR/NAR checks on file were dated in January or February 2025 and were completed by the previous HR Coordinator, with no prior annual checks available in their personnel files to demonstrate ongoing compliance with the facility’s policy. Additional deficiencies were identified for specific staff. For Social Worker B, whose date of hire was 09/18/25, the initial EMR/NAR report in the file was not dated; the HR Coordinator stated that the Tulip system was down when the check was completed and that she did not rerun the check once the system was operational. For LVN N, rehired on 12/01/23, and RN O, the HR Coordinator reported she could not find any criminal background check reports to show that criminal checks were completed upon rehire. The facility’s written policies and HR handbook require comprehensive background checks, including OIG, EMR/NAR, criminal history, and other databases, prior to employment and annually thereafter, but the documentation reviewed did not demonstrate that these requirements were consistently carried out or maintained in personnel files.
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