HospitalInspections.org

.
Based on record review and interview, the facility failed to meet the Condition of Participation of Patient Right's according to CFR 482.13. The facility failed to protect and promote patient's rights to be free from abuse and neglect. Findings:

The facility failed to ensure 76 staff were adequately screened for abuse and neglect, as well as maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Specifically, the facility failed to:

1) an employee (Staff #1) had a valid background check while working at the facility over a four-year period; and

2) 75 active employees (Staff #s 2 through 76) had continuous background check clearance during employment.
.

.
Based on record review and interviews, the facility failed to ensure 76 staff were adequately screened for abuse and neglect, as well as maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Specifically, the facility failed to:

1) an employee (Staff #1) had a valid background check while working at the facility over a four-year period; and

2) 75 active employees (Staff #s 2 through 76) had continuous background check clearance during employment.

This failed practice placed all patients at risk for abuse, neglect, and/or misappropriation. Furthermore, these failed practices resulted in lack of oversight from the Department of Health Background Check Unit due to failure to ensure employees were appropriately screened and maintained valid background check status. Findings:

Lack of Background Checks

Record review of the New Alaska Background Check System (NABCS) on 4/25/25 revealed Staff #1 had a valid background check from 11/28/14 through 4/14/21. NABCS automatically closed the background application when the eligibility expired on 4/14/21. As a result, the Staff #1 did not have a valid background check from 4/5/21 to 4/19/25.

Record review of the New Alaska Background Check System (NABCS) on 4/25/25 revealed that a background application was entered and paid for by the facility on 4/16/21. On 4/28-30/21 the Background Check Unit (BCU) identified a barrier crime, but did not make a final determination until a fingerprint card was received. On 7/31/22, the application was incomplete and closed due to the lack of submission of a fingerprint card.

Record review of Staff #1 timesheets, dated 4/1/21 through 4/19/25, revealed the Staff #1 worked a cumulative 7,772.29 hours at the facility.

During an interview on 4/24/25, Human Resources (HR) Staff #1 stated there were some inconsistencies in the background check process prior to his/her team taking on the responsibilities of background checks in December 2024. HR Staff #1 further stated the facility became aware of background check issues after receiving a letter from the State in March of 2025.

Record review of the facility's job description for "Certified Phlebotomist ...Job Code: 3372," undated, revealed job duties included "Performs specimen collection and patient preparation, ensuring correct patient and specimen identification and specimen integrity by using appropriate techniques as required. May perform assigned patient testing. May perform collections for drug and alcohol screening, following chain of custody protocols. May transport patient specimens and/or patients, per guidelines ... Performs registration processes including collecting insurance information, verifying coverage of Advanced Beneficiary Notices, obtain authorizations and signatures. Verifies patient demographics, insurance, and diagnostic test information, and accurately enters data into appropriate systems to ensure accurate documentation and billing."

Gaps in Background Check Clearance

Record review on 4/25/25 of the facility's active employee list, dated 4/24/25, in conjunction with Alaska Background Check System (NABCS) revealed the following employees were actively employed by the facility with gaps in background check clearance during the following dates:

Staff #2 - No clearance 1/10/22-12/2/24
Staff #3 - No clearance 1/16/23-1/22/23 & 3/25/23-8/11/24
Staff #4 - No clearance 1/27/23-12/22/24
Staff #5 - No clearance 1/3/25-3/23/25
Staff #6 - No clearance 1/3/25-4/6/25
Staff #7 - No clearance 1/6/14-3/12/14 & 12/28/18-10/2/20
Staff #8 - No clearance 10/05/23-current
Staff #9 - No clearance 10/1/18-12/15/19
Staff #10 - No clearance 10/11/21-12/21/21
Staff #11 - No clearance 10/18/21-11/15/21
Staff #12 - No clearance 10/18/21-11/15/21
Staff #13 - No clearance 10/18/21-11/16/21
Staff #14 - No clearance 10/20/14-11/23/14 & 4/3/19-2/5/20
Staff #15 - No clearance 10/22/17-9/1/20
Staff #16 - No clearance 10/22/20-6/6/21
Staff #17 - No clearance 10/23/18-11/23/20
Staff #18 - No clearance 10/24/16-4/26/18
Staff #19 - No clearance 10/3/20-3/17/21
Staff #20 - No clearance 10/30/23-1/7/24
Staff #21 -No clearance 10/4/21-10/27/21
Staff #22 - No clearance 10/5/20-11/7/22 & 9/2/23-9/17/23
Staff #23 - No clearance 10/7/21-4/21/24
Staff #24 - No clearance 10/9/19-10/10/19 & 5/16/20-8/1/23
Staff #25 - No clearance 11/1/21-11/16/21
Staff #26 - No clearance 11/1/21-11/23/21
Staff #27 - No clearance 11/11/19-3/4/20
Staff #28 - No clearance 11/15/21-12/12/21
Staff #29 - No clearance 11/18/21-11/15/21
Staff #30 - No clearance 11/23/21-12/12/21
Staff #31 - No clearance 11/24/21-12/12/21 & 9/9/22-6/18/23
Staff #32 - No clearance 11/25/20-12/9/20, 7/23/22-1/8/23 & 6/10/23-1/22/25
Staff #33 - No clearance 11/27/23-1/7/24
Staff #34 - No clearance 11/29/21-12/20/21
Staff #35 - No clearance 11/7/21-11/23/21
Staff #36 - No clearance 11/7/21-12/2/21
Staff #37 - No clearance 11/8/21-11/23/21
Staff #38 - No clearance 11/8/21-11/25/21
Staff #39 - No clearance 12/11/20-1/10/21
Staff #40 - No clearance 12/11/23-1/7/24
Staff #41 - No clearance 12/12/21-12/21/21
Staff #42 - No clearance 12/13/21-12/29/21
Staff #43 - No clearance 12/16/19-1/8/20
Staff #44 - No clearance 12/19/22-1/8/23
Staff #45 - No clearance 12/19/24-current
Staff #46 - No clearance 12/2/21-2/20/22
Staff #47 - No clearance 12/20/20-9/28/22
Staff #48 - No clearance 12/28/19-11/11/24
Staff #49 - No clearance 12/31/22-9/10/23
Staff #50 - No clearance 12/9/20-10/28/21
Staff #51 - No clearance 2/14/20-6/17/20
Staff #52 - No clearance 2/15/21-12/31/24
Staff #53 - No clearance 2/2/15-10/28/21 & 10/17/23-6/23/24
Staff #54 - No clearance 2/20/25-4/13/25
Staff #55 - No clearance 2/23/20-3/17/24
Staff #56 - No clearance 2/9/20-9/22/24
Staff #57 - No clearance 3/16/20-9/29/20
Staff #58 - No clearance 3/2/19-9/29/20
Staff #59 - No clearance 3/21/11-7/4/16 & 5/8/18-10/31/20
Staff #60 - No clearance 3/27/20-3/30/20 & 4/3/21-1/10/22
Staff #61 - No clearance 3/27/22-3/28/22 & 4/5/22-11/12/23
Staff #62 - No clearance 3/30/22-2/5/23
Staff #63 - No clearance 3/5/20-10/31/20
Staff #64 - No clearance 3/6/20-10/31/20
Staff #65 - No clearance 4/19/16-1/8/17 & 10/15/20-10/20/20
Staff #66 - No clearance 4/2/21-7/18/22
Staff #67 - No clearance 4/23/20-5/10/20 & 6/28/20-9/7/20
Staff #68 - No clearance 5/19/22-5/30/22 & 8/13/22-7/14/24
Staff #69 - No clearance 5/21/23 & 5/13/24-6/17/24
Staff #70 - No clearance 6/19/20-10/1/20 & 4/5/21-4/7/21
Staff #71 - No clearance 6/21/21-10/20/21; 11/13/21-6/18/23
Staff #72 - No clearance 6/5/22-6/14/22 & 8/3/23-3/24/24
Staff #73 - No clearance 7/19/21-current
Staff #74 - No clearance 8/18/23-9/24/23 & 4/17/25-4/21/25
Staff #75 - No clearance 8/19/19-11/15/21
Staff #76 - No clearance 8/24/20-9/1/20 & 1/7/23-6/4/23

Review of the facility provided document "State Background Check - HR process, undated, revealed "Employees, Students and Volunteers are required to renew their Alaska Background Checks every five years. This is coordinated by the HR Coordinator, Talent Development Coordinator, Voluntary Services Coordinator. The background check renewal process begins 60 days from the expiration date. An email is sent to the employee and their leader within FHP. The employee is required to fill out the renewal application and submit that to the HR Coordinator. Once the HR Coordinator receives the application it is entered into the State of Alaska Database. After the application is finalized, the employee will then have their fingerprints taken with the Security Badging office. HR will mail fingerprints and applications the next business day via FedEx. It has been FHP's philosophy to put every position through the background check process to ensure 100% compliance."

.