Failure to Complete Required Background Checks: The facility's abuse prevention policies did not include the background check procedure for new and existing employees, and review of staff records showed that a CNA had a completed BID form but no DOJ or Government Findings Reports on file. The HR Director confirmed the required reports had not been completed prior to surveyor review.
Outdated employee background screening records were found during file review, including BID, DOJ, and IBIS forms that were not updated within the required timeframe for an RN, a housekeeper, and a CNA. Another CNA’s BID form was undated, so completion within the required period could not be verified. The NHA acknowledged the records were outdated and stated that new forms had been requested.
The facility did not maintain required written abuse, neglect, exploitation, and misappropriation prevention procedures and did not complete BID, DOJ response, and IBIS screening every 4 years for two CNAs. During record review, the surveyor found that the screening documents for CNA-M and CNA-V were older than the required timeframe, and HRD-S could not locate updated background checks for either employee. The concern was shared with the NHA, DON, director of operations, and regional nurse consultant.
Incomplete Background Check for RN-E: The facility did not fully implement its abuse, neglect, and exploitation screening policy for an RN. Although part of the background check was completed before hire, the DOJ and Governmental Findings reports were dated much later, and the agency that supplied the RN said the file had been deleted. The NHA stated the facility should have completed all pre-employment screening before employment and retained copies of the screening documents.
An LPN was cited after the facility failed to complete and document required BID, IBIS, and DOJ background checks upon hire and every 4 years thereafter, as required by its abuse, neglect, and exploitation policy. During survey review, the NHA confirmed there was no documentation of the required checks and stated they should have been completed on the required schedule.
The facility failed to follow its abuse prevention policy by not completing required criminal background checks before hiring 4 of 8 employees reviewed. Records showed that an RN, a life enrichment staff member, and 2 CNAs had DOJ/IBIS and related background checks completed after hire, and one staff member also had an out-of-state check completed late. The NHA stated background checks had not been done for new hires before the NHA began working at the facility and agreed this was a problem.
A facility failed to follow its abuse prevention and employee screening policy for a newly hired cook. The cook’s BID showed prior residence in Iowa and [NAME] Virginia, but the required background checks for those states were not in the file. During interview, the NHA confirmed the checks had been missed and should have been completed.
Failure to complete required background check for CNA. The facility did not ensure its abuse, neglect, and exploitation policy was followed for a CNA whose BID form showed prior residence outside WI within the previous 3 years. Record review and staff interview showed the required out-of-state background check was not completed before hire, and the GSC and NHA both stated it should have been done prior to employment.
A facility failed to follow its abuse-prevention background check process for an RN whose BID showed a recent military discharge. The RN’s file did not include the required DD214, and the NHA confirmed the document was missing and had only just been requested.
Failure to Complete Required Pre-Employment Background Screening: The facility did not follow its abuse policy requiring pre-employment background screening for all employees. Review of employee records found that one employee disclosed prior residence in Minnesota within the last 3 years, but no out-of-state background information disclosure was completed before the employee began working. The NHA confirmed the review had not been done and said the facility was completing it.
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