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Based on review of Medical Staff Bylaws, medical staff credential files, and staff interviews, the Critical Access Hospital (CAH) governing body failed to grant specific privileges for 4 of 12 Physician credential files reviewed. (Physicians A, B, C, D)

Failure of the governing body to grant the CAH physicians specific privileges could potentially result in failure to provide patient care within the physician's scope of practice resulting in patient harm, illness, or even patient death.

Findings include:

1. Review of Medical Staff Bylaws, dated 4/12/11, stated in part ". . . Privileges to practice at the Health Center are granted by the Board following recommendation of the Medical Staff. . . A Practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws. . . ."

2. Review of medical staff credential files for 12 Physicians revealed Physicians A, B, C, D lacked evidence of specific privileges approved by the governing body. Privileges for Physicians A, B, C, D stated only "Teleradiology".

3. During an interview on 9/20/11 at 2:20 PM, Staff K, Credentialing Coordinator, acknowledged the privileges for Physicians A, B, C, D stated only Teleradiology and lacked of specific privileges. Staff K stated the teleradiologists read general x-rays and CT Scans.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician reviewed the CAH patient records periodically, in conjunction with the mid-level practitioner for 6 of 6 mid-level practitioners. (Practitioners F, G, H, I, J, K)

The Quality/Credentialing Coordinator reported the volume of services by mid-level provider over the past 12 months as follows:
- Practitioner F - In-patients - 4; Observation patients - 7; Out-patients - 237
- Practitioner G - In-patients - 10; Observation patients - 10; Out-patients - 401
- Practitioner H - In-patients - 18; Observation patients - 29; Out-patients - 432
- Practitioner I - Out-patients - 109
- Practitioner J - Out-patients - 80
- Practitioner K - Out-patients - 30

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "MD/DO Periodic Review of PA and/or ARNP Records, dated reviewed 6/10, stated in part, ". . . Purpose: This purpose will met by having the doctor of medicine or osteopathy, in conjunction with the physician assistant and/or nurse practitioner members, periodically review the CAH's patient medical records, provide medical orders, provide medical care services to the patients of the CAH. This review will also provide educational opportunities as well as keep in compliance with CMS regulations. . . Procedure: In order to comply with CMS Tags C259; C339 and C264 MD/DO Responsibilities and PA and NP Record Review a periodic random sample of physician assistant and/or nurse practitioner's inpatient charts will be reviewed in conjunction with the doctor of medicine or osteopathy. . . ."

Review of CAH policy/procedure titled "Practice Record Review", dated revised 9/2011, stated, in part, ". . . Mid-Level practitioner record review: Ongoing periodic review of a sample of mid-level practitioners patient records is required by CMS as part of the Conditions of Participation (Tag C-259, C-339, C-264). The quality and appropriateness of the diagnosis and treatment furnished by Nurse Practitioners and Physician Assistants at KCHC are evaluated by a MD/DO if the KCHC medical Staff. . . ."

2. Review of Medical Staff Rules and Regulations, dated approved 4/12/11, stated, in part, ". . . The physician assigned as a supervisor or collaborating physician in conjunction with a mid-level practitioner, must participate in a review of inpatient charts no less than once per quarter. . . ."

3. During an interview on 9/21/11 at 11:20 AM, Staff K, Quality/Credentialing Coordinator, stated the physician reviewed the mid-level records of CAH patients, filled out the form, sign and then the mid-level provider reviewed the form and signed later. Staff K also stated the physician may review of the mid-level records of CAH patients over the telephone with the mid-level but only the physician would have the record for review. Staff K acknowledged the physician failed to review the CAH patient records in conjunction with the mid-level practitioner.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the mid-level practitioner participated with the review of the CAH patient records periodically, for 6 of 6 mid-level practitioners. (Practitioners F, G, H, I, J, K)

The Quality/Credentialing Coordinator reported the volume of services by mid-level provider over the past 12 months as follows:
- Practitioner F - In-patients - 4; Observation patients - 7; Out-patients - 237
- Practitioner G - In-patients - 10; Observation patients - 10; Out-patients - 401
- Practitioner H - In-patients - 18; Observation patients - 29; Out-patients - 432
- Practitioner I - Out-patients - 109
- Practitioner J - Out-patients - 80
- Practitioner K - Out-patients - 30

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "MD/DO Periodic Review of PA and/or ARNP Records, dated reviewed 6/10, stated in part, ". . . Purpose: This purpose will met by having the doctor of medicine or osteopathy, in conjunction with the physician assistant and/or nurse practitioner members, periodically review the CAH's patient medical records, provide medical orders, provide medical care services to the patients of the CAH. This review will also provide educational opportunities as well as keep in compliance with CMS regulations. . . Procedure: In order to comply with CMS Tags C259; C339 and C264 MD/DO Responsibilities and PA and NP Record Review a periodic random sample of physician assistant and/or nurse practitioner's inpatient charts will be reviewed in conjunction with the doctor of medicine or osteopathy. . . ."

Review of CAH policy/procedure titled "Practice Record Review", dated revised 9/2011, stated, in part, ". . . Mid-Level practitioner record review: Ongoing periodic review of a sample of mid-level practitioners patient records is required by CMS as part of the Conditions of Participation (Tag C-259, C-339, C-264). The quality and appropriateness of the diagnosis and treatment furnished by Nurse Practitioners and Physician Assistants at KCHC are evaluated by a MD/DO if the KCHC medical Staff. . . ."

2. Review of Medical Staff Rules and Regulations, dated approved 4/12/11, stated, in part, ". . . The physician assigned as a supervisor or collaborating physician in conjunction with a mid-level practitioner, must participate in a review of inpatient charts no less than once per quarter. . . ."

3. During an interview on 9/21/11 at 11:20 AM, Staff K, Quality/Credentialing Coordinator, stated the physician reviewed the mid-level records of CAH patients, filled out the form, sign and then the mid-level provider reviewed the form and signed later. Staff K also stated the physician may review of the mid-level records of CAH patients over the telephone with the mid-level but only the physician would have the record for review.

Based on observations, review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) pharmacy administrative staff failed to ensure the Pharmacy & Therapeutics Committee reviewed and approved policies and procedures related to the use of drugs in the hospital as specified by policy/procedure. (Pediatric Clinic) The CAH clinic staff reported an average of 30 clinic patients per week.

Failure to ensure the implementation of policies/procedures related to the use of drugs in the hospital could potentially cause the unsafe use of medications, thus not providing desired effect to patients and potentially cause harm to patients.

Findings include:

1. Tour of the Pediatric Clinic on 9/21/11 at 8:00 AM revealed sample medications stored in a locked cupboard.

2. Review of Pediatric Clinic policy/procedure titled "Maintenance of Sample Medications", dated effective 4/28/11, stated, in part, ". . . It is the policy of Keokuk County Pediatric Clinic to maintain sample medications appropriately. . . ."

3. Review of Pharmacy policy/procedure titled, "Pharmacy & Therapeutics Committee", dated reviewed 3/09, stated, in part, ". . .Purpose: The P and T committee is responsible for the development f policies and procedures for ensuring the safety and quality of medication therapy. . . The charge of the committee is to perform the following functions as related to the use of medications within the hospital. . . Review and approve policies and procedure related to the use of drugs in the hospital. . . ."

4. Review of the Pharmacy & Therapeutics Committee Meeting minutes dated 4/22/11 and 6/17/11 lacked documentation of approval of the sample medication policy/procedure for the Pediatric Clinic.

5. During an interview on 9/21/11 at 11:10 AM, Staff L, Pharmacist, acknowledged the
Pharmacy & Therapeutics Committee failed to approve the sample medication policy/procedure for the Pediatric Clinic.

I. Based on observation, review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) pharmacy staff failed to ensure pharmacy oversight of the receipt and distribution of sample medications in the hospital. (Pediatric Clinic) The CAH clinic staff reported an average of 30 clinic patients per week.

Failure of pharmacy staff to provide oversight of sample medications could potentially result in expired medications being available for physicians to give to patients, and the potential theft of medications by unauthorized persons.

Findings include:

1. Observation during tour of the Pediatric Clinic on 9/21/11 at 8:00 AM with Staff M, Clinic Supervisor, revealed 1 of 2 drug storage cupboard that contained approximately 35 sample medications. Categories of medications included in the cupboard were to treat psychiatric conditions.

2. Review of Pharmacy policies/procedures revealed the lack of a policy/procedure related to the receipt and distribution of sample medications in the hospital.

Review of Pharmacy policy/procedure titled "Pharmacist in Charge", dated reviewed 3/09, stated, in part, ". . . The Pharmacist in charge shall be responsible for, at a minimum, the items identified as follows: . . . Procuring and storing prescription drugs and devices and other products dispensed from the pharmacy. . . ."

Review of Pharmacy policy/procedure titled "Drug Procurement/Inventory Control" dated reviewed 3/09, stated, in part, ". . . Responsibility for control of medications within this Hospital rests with the Pharmacy Department. . . Policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the hospital. . . Acquisition: The Pharmacist is responsible for the acquisition of medications for the Hospital. . . ."

Review of Pediatric Clinic policy/procedure titled "Maintenance of Sample Medications", dated effective 4/28/11, stated, in part, ". . . It is the policy of Keokuk County Pediatric Clinic to maintain sample medications appropriately. . . ."

3. During an interview on 9:20/11 at 4:40 PM, Staff L, Pharmacist, stated the Pediatric Clinic keep sample medications but the Pharmacy staff has not provided any oversight over those sample medications.

During an interview on 9/21/11 at 8:00 AM, Staff M, Clinic Supervisor, acknowledged the lack of Pharmacy staff oversight of the sample medications.


II. Based on observations, review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) pharmacy administrative staff failed to ensure the pharmacy staff inspected all drug storage areas within the CAH at least monthly as specified in policies/procedures. (Pediatric Clinic) The CAH clinic staff reported an average of 30 clinic patients per week.

Failure of pharmacy staff to inspect all drug storage areas for expired medications could potentially expose patients to expired medications that may be harmful to the patient or have diminished effectiveness.

Findings include:

1. Observation during tour of the Pediatric Clinic on 9/21/11 at 8:00 AM with Staff M, Clinic Supervisor, revealed 1 of 2 drug storage cupboard that contained approximately 40 medications provided to the clinic by the CAH pharmacy. Categories of medications included in the cupboard were to treat allergies, infections, and respiratory conditions.

2. Review of Pharmacy policy/procedure titled "Unit Inspection", dated revised 3/09, stated, in part, ". . .A pharmacist/pharmacy technician will inspect all drug storage areas within the Keokuk County Health Center at least monthly. The purpose is to ensure proper storage f medications. . . The pharmacist will direct the monthly inspection of all drug storage areas in the hospital. A written record of these inspections will be maintained. . . ."

Review of Pharmacy policy/procedure titled "Drug Procurement/Inventory Control" dated reviewed 3/09, stated, in part, ". . . Responsibility for control of medications within this Hospital rests with the Pharmacy Department. . . Inspections: The pharmacist, pharmacy technician, or nurse will inspect all drug storage areas within the Hospital monthly. . . ."

3. During an interview on 9/21/11 at 8:00 AM, Staff M, Clinic Supervisor, stated Pharmacy staff does not inspect the drug storage areas in the Pediatric Clinic.

During an interview on 9/21/11 at 11:10 AM, Staff L, Pharmacist, acknowledged Pharmacy staff does not inspect the drug storage areas in the Pediatric Clinic.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure physician notification for the occurrence of a medication error for 6 of 15 medication errors reviewed. (Patients # 1, 2, 3, 4, 5, 6) The CAH administrative staff reported a census of 6 patients.

Failure to notify the physician of medication errors could potentially result in life threatening conditions, or other related health conditions that could lead to serious harm.

Findings include:

1. Review of the CAH Nursing policy/procedure titled "Medication Administration", dated reviewed 3/09, stated in part, ". . . Errors in administration of medication will be reported immediately to the attending provider and the Director of Patient Care. . . ."

2. Review of the CAH Pharmacy policy/procedure titled "Medication Errors", dated reviewed 3/09, stated in part, ". . . When a medication error occurs, two things should occur in this order: a. Notify the physician and evaluate the patient. b. Report the error in detail with an incident/occurrence report. . . ."

3. Review of the medication errors from March 2011 to September 2011 revealed 6 of 15 medication errors lacked the date and time of physician notification of the medication errors. (Patients # 1, 2, 3, 4, 5, 6)

3. During an interview on 9/20/11 at 4:30 PM, Staff J, Director of Nursing, acknowledged the lack of documentation of physician notification of the medication errors for Patients # 1, 2, 3, 4, 5, 6.

Staff J stated the nurses last received education at the Nurse's Meetings on April 27, 2011 and July 20, 2011 regarding the requirement of documentation of the physician notification of the occurrence of a medication error per CAH policy.

I. Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) dietary staff failed to ensure outdated food was removed from storage. The CAH administrative staff reported a census of 6. The Dietary Manager reported the dietary staff provided approximately 24 patient meals daily.

Failure to remove outdated food from storage could potentially result in a patient acquiring a foodborne illness.

Findings include:

1. During the initial kitchen tour on 9/19/11 at 10:30 AM, the double-door True refrigerator contained a quart plastic bag labeled diced chicken with a date of 9/13/11. In an interview at the time, Staff B, cook, reported leftover food items are dated at the time of storage, with that date counted as day 1. She further reported leftover food items are discarded on day 7.

Observation on 9/20/11 at 7:25 AM, revealed the diced chicken, dated 9/13/11, remained in the double-door True refrigerator.

2. Review of a dietary policy titled "Infection Control-Prevent and Control Contamination", approved March 2011, revealed in part "... F. Procedures for the handling, preparation and serving of food shall meet the standards of all regulatory bodies. ... R. All foods that have been prepared for service, but not shredded or chopped shall be covered, dated and discarded after seven days, if not used and is maintained at 41 degrees F or less. ...".

Review of the Food and Drug Administration Food Code 2005 (a model for safeguarding public health by addressing the safety and protection of food offered at retail and in food service), section 3-501.17, revealed in part " ... refrigerated, ready-to-eat, potentially hazardous food (a food that requires time/temperature control for safety to limit pathogenic microorganism growth or toxin formation) ... prepared and held in a food establishment for more than 24 hours, shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded based on the temperature and time combinations specified below. The day of preparation shall be counted as Day 1.
(1) 5?Celsius (41?Fahrenheit) or less for a maximum of 7 days ...".

3. During an interview on 9/20/11 at 7:55 AM, Staff A, dietary manager, reported the cooks are responsible to check for and remove outdated food from storage on day #7.


II. Based on observation, policy review and staff interviews, the CAH failed to ensure hair was effectively restrained in food preparation areas. The CAH administrative staff reported a census of 6. The Dietary Manager reported the dietary staff provided approximately 24 patient meals daily.

Failure to ensure effective hair restraint in food preparation areas could potentially result in the contamination of the patient's food.

Findings include:

1. Upon entrance into the kitchen for the initial tour, on 9/19/11 at 10:30 AM, Staff E, Chief Executive Officer, escorted surveyor into the food preparation area of the kitchen and failed to don a hair restraint.

Observation during the initial tour on 9/19/11 at 10:30 AM, revealed Staff B's hairnet started at the crown of the head and covered only the back of the head. Additional observation from 11:15 AM to 11:38 AM, during the noon meal service, and again at 1:15 PM, revealed Staff B's hairnet remained in a position to cover only the back of the head.

Observation on 9/19/11 at 10:55 AM, revealed Staff C, laundry, entered the kitchen and failed to don a hair restraint. Staff C entered the food preparation area of the kitchen and placed laundered items in a drawer, near the microwave.

2. Review of a dietary policy titled "Infection Control-Prevent and Control Contamination", approved in March 2011, revealed in part " ... I. Personnel: Employees shall be expected to keep themselves clean, bathe daily, wear clean uniforms at all times, have clean hair covered with a hairnet including beards and mustaches ...".

Review of the Food and Drug Administration Food Code 2005, section 2-402.11, stated in part "... food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens ... ".

3. During an interview on 9/20/11 at 7:25 AM, Staff D, cook, reported dietary staff have a choice on which type of hair restraint to wear but are required to keep all hair covered when in the kitchen.

During an interview on 9/20/11 at 7:55 AM, Staff A reported dietary staff are required to cover the entire head, with a hair restraint. She further reported she has had to ask Staff B to adjust her hair restraint appropriately, when noted to be back to the crown of her head. Staff A confirmed non-dietary employees have not been required to don a hair restraint upon entrance into the food preparation area of the kitchen and acknowledged the potential for concern over this practice.

Based on observation, facility menu review and interview, the Critical Access Hospital (CAH) dietary staff failed to follow the planned menu approved by the CAH dietitian, for 1 of 1 patients (Patient #1) on a pureed diet. The CAH administrative staff reported a census of 6.

Failure to followed the planned menu could potentially result in inadequate nutrient intake and compromise of the patient's nutritional status.

Findings include:

1. Review of the facility's Week 5 menu identified hamburger stroganoff, noodles, peas and bread with margarine as part of the planned menu for the pureed diet at the noon meal on 9/19/11.

2. Observation on 9/19/11 at 11:15 AM revealed Staff B, cook, pureed and served a serving of hamburger stroganoff, noodles and peas to Resident #1. Staff B failed to puree and serve the bread and margarine to Resident #1, as specified on the facility menu.

3. Review of a document titled "KCHC Dietary Order Sheet" dated 9/19/11, revealed a diet order of Pureed, high fiber, high protein for Resident #1.

4. During an interview on 9/20/11 at 7:55 AM, Staff A, dietary manager, reported dietary staff are trained to follow the planned menu and confirmed Staff B should have included a serving of pureed bread with margarine for Resident #1, at the noon meal on 9/19/11.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals reviewed all patient care policies annually for 18 of 18 patient care departments. (Activities, Ambulance, Cardiac Rehabilitation, CT Scan - Imaging, Dietary, Emergency Room, Housekeeping, Health Information Management, Infection Control, Laboratory, Laundry, Maintenance, Nursing, Pediatric Clinic, Pharmacy, Physical Therapy, Social Services/Discharge Planning, Utilization Review) The CAH administrative staff identified a census of 6 patients.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in CAH policies/procedures.

Findings include:

1. Review of policy/procedure titled, "CAH - Annual Total Program Review", dated reviewed 3/10, revealed in part. ". . .The Professional Advisory committee is a committee that meets once per year, specifically to review the Department Policy and Procedure Manuals and Total Program Evaluation. . . Professional Advisory Committee for Keokuk County Health Center consists of: Physicians, Mid-level Providers, Chief Executive Officer, Representatives from the Administrative Team, Representative from the Board of Trustees (Member at Large/non-CAH staff member), Network Hospital Liaison. . . ."

2. Review of Professional Advisory Committee Meeting minutes from March 16, 2011 documented the absence of the physician and mid-level provider at the meeting. The meeting minutes stated, in part, ". . . Annual Review of Department Policy and Procedures Manual . . . Policy and Procedure Changes 2010: List f all policies and procedures that were updated during 2010. . . ." Motion made to approve Policies and Procedures and motion carried.

3. During an interview on 9/21/11 at 1:45 PM, Staff K, Quality/Credentialing Coordinator, acknowledged the mid-level provider was not present at the Professional Advisory Committee Meeting on March 16, 2011 for annual review of the CAH's policies/procedures. Staff K stated the physician arrived late at the meeting but the minutes failed to reflect the physician's late arrival. Staff K reported the mid-level provider received, after the meeting, a sheet of a summary of policy/procedure changes during the previous year. Staff K stated the policies/procedures would be available to the mid-level if the mid-level had questions, but the mid-level did not have any questions and signed the annual approval of policies/procedures on 3/25/11.

Based on review of documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to maintain complete list of contracted services that described the nature and scope of the services provided. The CAH identified a list of 9 contracted services.

Lack of a complete list of contracted services including the delineation of the nature and scope of contracted services could potentially result in failure of compliance of the contracted services' responsibilities.

Findings include:

1. Review of documents requested revealed current contracts/agreements for the Iowa Donor Network, Iowa Lions Eye Bank, Agreement for Dental Care, Anderson Erickson - Water Supply Confirmation, and New Alliance FS - emergency fuel supply.

2. Review of the list of contracted services revealed the list failed to include contracts/agreements for the Iowa Donor Network, Iowa Lions Eye Bank, Agreement for Dental Care, Anderson Erickson - Water Supply Confirmation, and New Alliance FS - emergency fuel supply.

3. Review of the list of contracted services revealed the list lacked delineation of the nature and scope of services each contracted entity would provide.

4. During an interview on 9/21/11 at 3:30 PM, Staff A acknowledged the list of contracted services failed to include all services furnished under arrangements or agreements and lacked a description of the nature and scope of the services provided.

Based on observation, review of policies/procedures, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to protect all confidential patient information from unauthorized access in 1 of 1 Laboratory. The CAH administrative staff identified an average of 365 in-patient laboratory exams per month and an average of 2368 out-patient laboratory exams per month.

Failure to secure medical records against unauthorized access could result in identity theft and/or unauthorized disclosure of personal medical information.

Findings include:

1. Observations on 9/19/11 at 3:15 PM, during the tour of the Laboratory department, with Staff F, Laboratory Supervisor, revealed the following:
- 1 of 1 file box in an unlocked cupboard. The file box, labeled February 10 - December 10, contained approximately 803 CBC (blood test) results for every patient during that time period.
- 1 of 1 unlocked file drawer that contained approximately 2000 reports, copies of all laboratory results drawn for the time period of January 2011 - September 2011.

2. During an interview on 9/19/11 at 3:15 PM, Staff F, Laboratory Supervisor stated the housekeeping staff cleaned the Laboratory department before the Laboratory staff arrived. Staff F further acknowledged Laboratory staff was not present when the housekeeping staff cleaned the department.

3. During an interview on 9/20/11 at 8:00 AM, Staff G, Housekeeping Supervisor, stated the housekeeping staff had access to the Laboratory department and entered the department before Laboratory staff arrive to clean the department when no Laboratory staff were present.

4. Review of CAH policy/procedure titled, "Secure Filing of Medical Records", dated reviewed 8/11, stated in part ". . . Policy: It is the policy of Keokuk County Health Center that the medical records are maintained in a secure and confidential manner. . . Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to authorized individuals. . . ."

Based on review of employee personnel files, policies/procedures, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the completion of criminal background checks, including any follow up required, for all employees prior to hire for 2 of 8 new hire employee personnel files reviewed. (Staff H, I) The CAH staff reported a current census of 6 patients.

Failure to complete criminal background checks, including any follow up required, for all new hire employees could potentially expose patients to individuals with a conviction of abusing, neglecting, or mistreating individuals in a health care related setting.

Findings included:

1. Review of CAH policy/procedure titled "New Hire Policy", dated revised 8/11, stated in part ". . . Criminal background checks, dependent, adult, child abuse check, and license checks will be done by internet prior to starting employment. . . ."

2. Review of employee personnel files revealed the following:

a. Staff H
- a hire date of 7/16/11
- a criminal history background check completed 6/24/11 with a possible hit
- the personnel file lacked a follow up of the possible hit dated 6/24/11

b. Staff I
- a hire date of 5/4/11
- a criminal history background check completed 5/2/11 with a possible hit
- the personnel file contained a follow up to the possible hit on 5/5/11 - not available prior to hire

3. During an interview on 9/20/11 at 4:15 PM, Staff A, Human Resources, acknowledged the lack of completion of a follow up of a possible hit on the criminal history background check for Staff H and I prior to hire.