Failure to Maintain Timely 4‑Year Background Check for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding required 4‑year background checks for employees. The written policy dated 3/2/2026 states that potential employees, contracted staff, students, volunteers, and consultants will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that the facility will maintain documentation proving that such screenings occurred. Record review showed that a CNA hired on 11/2/2020 had an initial Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, and Interagency Border Inspection System (IBIS) form completed on 9/25/2020, prior to employment, but the next documented background check was not completed until 3/10/2026, after the surveyor requested the information. During interviews, the Director of Human Resources acknowledged that when the surveyor requested the CNA’s background check information, it was discovered that no updated background check had been completed within the required four‑year period. The Nursing Home Administrator reported that the facility was purchased by another company in 2022 and stated that all employees had background checks completed in June and July of that year, but at the time of the initial request they were unable to locate the documentation. Later, the Administrator provided a DOJ letter and BID form for the CNA dated 2/10/2022, establishing that a new background check should have been completed by 2/10/2026. The surveyor determined that the background check completed on 3/10/2026 occurred beyond the four‑year timeline and only after it was requested, demonstrating noncompliance with the facility’s abuse prevention screening requirements for one of eight employees reviewed, potentially affecting a portion of the 97 residents in the facility.
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