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Based on review of credential files, review of Medical Staff Bylaws, review of the Credentialing Service Agreement, review of the Network agreement with a Nebraska hospital (Network Hospital) for quality assurance, review of the CAH's (Critical Access Hospital's) Quality Improvement Plan and staff interview, the governing body of the CAH failed to ensure that:
- The Medical Staff Bylaws were followed in the reappointment of 6 of 7 physicians (both Active and Courtesy Staff - Physicians L, M, N, O, P and Q) and 4 of 5 Affiliate Staff (Affiliate Staff - R, T, V and W) reviewed (Refer to C-0241);
- The CAH followed the Network Hospital's plan for review of quality and appropriateness of diagnosis and treatment furnished by physicians at the CAH (Refer to C-0340).

This failed practice has the potential to affect all patients treated by active, courtesy and affiliate members of the medical staff at the CAH. The inpatient census from August 2012 through July 2013 was 80. On the first day of survey patient census was 1 acute inpatient and 2 skilled inpatients. The roster of Medical Staff provided by the CAH listed 1 Active Staff, 8 Affiliate Staff and 65 Courtesy Staff.

Findings are:

A. Review of the Medical Staff Bylaws dated 3/16/09, 11/26/12 and July 2013 all revealed the following concerning clinical privileges and reappointment process:

Article IV Clinical Privileges
"4.2 Qualifications. The following constitute continuing qualifications for the exercise of privileges at the Hospital. Each member and applicant for membership shall:"
"f. Competence. Demonstrate current competence, including current knowledge. judgment, training, and technique, in his or her specialty area and for all privileges held or applied for."

Article VI Appointment and Privileging
6.6 Reappointment/Renewal Process
"c. Information: In reviewing applications for appointment and renewal of privileges, the Executive Committee and Board will not be limited to review of information supplied within or in support of the application, but may review and consider any other records and information deemed relevant to their review. Without limitation, this may include review of such items as Board, Medical Staff, or committee meeting minutes or records, utilization review, quality reports...complaints or comments from other members of the Hospital staff, the Administrator, patients, or members of the public; and any other relevant documents or correspondence..."

Review of the Credentialing Service Agreement dated 4/4/96 revealed the credential verification organization would provide the following documents from original sources for applicants for reappointment: Licensure; Federal Drug Enforcement Administration Registration; Current professional liability insurance and claims history; Board certification; National Practitioner Data Bank; Medicare sanction review activity; Continuing medical education (since last reappointment); Institutional affiliations references; and, Professional references.

Review of the credential files for Active and Courtesy Staff L, M, N, O, P and Q and Affiliate Staff R, T, V and W revealed the only information available was the information provided by the credentialing verification organization. Interview with the Interim CEO (Chief Executive Officer) on 8/7/13 from 4:15 PM to 4:30 PM and with the Interim CEO and HIM (Health Information Management) Manager on 8/8/13 from 8:15 AM to 9:15 AM revealed the following:
- Confirmed that the only information available to the Medical Staff and the Governing Body at the time of reappointment would be the information provided by the credentialing organization;
- No information related to quality and current competency from Harlan County Health System was available.

B. Review of a Network Agreement dated 8/1/09 between HCHS (Harlan County Health System) and the Network Hospital revealed HCHS had an agreement with the Network Hospital for assistance with the peer review process.

Review of the Quality Improvement Plan (effective date 9/8/10) revealed HCHS would work with the Critical Access Hospital Network in conjunction with Network Hospital to complete the peer review process.

(Peer review is the process by which a committee and/or another physician examines the work of a peer and determines whether the physician under review has met accepted standards of care in rendering medical services.)

Interview with the Interim CEO on 8/7/13 from 4:15 PM to 4:30 PM and with the Interim CEO and the HIM Manager on 8/8/13 from 9:25 AM to 10:10 AM revealed the following:
- HIM Manager (hire date of 11/1/12) confirmed that there has been no "Peer Review" since starting position.
- Interim CEO confirmed the CAH had completed no "Peer Review" from June 2012 through November 2012.
- HIM Manager had a Peer Review file and confirmed that the last Peer Review Audit Sheets in that file were from October 2011.
- Interim CEO indicated that about 3 months ago HCHS was going to send records to another CAH for peer review but the Quality Assurance person of the other CAH indicated their physicians were too busy and no records were sent.
- Interim CEO confirmed that the Network Hospital was not contacted about the other CAH not being able to complete peer review for HCHS.

Based on review of credential files, review of Medical Staff Bylaws, review of the Credentialing Service Agreement and staff interview, the CAH (Critical Access Hospital) failed to ensure that the Medical Staff followed their Bylaws in regards to:
- Reappointment of 6 of 7 physicians reviewed (both Active and Courtesy Staff - Physicians L, M, N, O, P and Q) ; and,
- Reappointment of 4 of 5 Affiliate Staff (podiatrists, physician assistants and certified registered nurse anesthetists - Affiliate Staff - R, T, V and W).

This failed practice had the potential to affect all patients of the CAH. The inpatient census from August 2012 through July 2013 was 80. On the first day of survey patient census was 1 acute inpatient and 2 skilled inpatients. The roster of Medical Staff provided by the CAH listed 1 Active Staff, 8 Affiliate Staff and 65 Courtesy Staff.

Findings are:

A. Review of the Medical Staff Bylaws dated 3//16/09, 11/26/12 and July 2013 all revealed the following concerning membership, medical staff categories, clinical privileges and reappointment process:

Article III Membership,
"3.1 Nature of Membership. Membership on the Medical Staff including assignment to a staff category is granted by the Board following recommendation of the Medical Staff."
"3.3 Active Staff. The Active Staff consists of physicians who meet all the criteria for clinical and admitting privileges, who regularly admit and attend patients at the Hospital...."
"3.4 Courtesy Staff. The Courtesy Staff consists of physicians who periodically render services at the Hospital but who do not wish to become members of the Active staff...."
"3.5 Affiliate Staff. The Affiliate Staff consists of non-physician practitioners who qualify for membership and clinical privileges of the Hospital, including co-admitting privileges....The Affiliate Staff includes dentists, podiatrists, physician assistants (PAs), advanced practice registered nurses (APRNs), certified registered nurse anesthetists (CRNAs)...."

Article IV Clinical Privileges
"4.2 Qualifications. The following constitute continuing qualifications for the exercise of privileges at the Hospital. Each member and applicant for membership shall....
f. Competence. Demonstrate current competence, including current knowledge. judgment, training, and technique, in his or her specialty area and for all privileges held or applied for."

Article VI Appointment and Privileging
6.6 Reappointment/Renewal Process
"c. Information: In reviewing applications for appointment and renewal of privileges, the Executive Committee and Board will not be limited to review of information supplied within or in support of the application, but may review and consider any other records and information deemed relevant to their review. Without limitation, this may include review of such items as Board, Medical Staff, or committee meeting minutes or records, utilization review, quality reports...complaints or comments from other members of the Hospital staff, the Administrator, patients, or members of the public; and any other relevant documents or correspondence..."

B. Review of the Credentialing Service Agreement dated 4/4/96 revealed the credential verification organization would provide the following documents from original sources for applicants for reappointment:
- Licensure
- Federal Drug Enforcement Administration Registration
- Current professional liability insurance and claims history
- Board certification
- National Practitioner Data Bank
- Medicare sanction review activity
- Continuing medical education (since last reappointment
- Institutional affiliations references
- Professional references

C. Review of the credential files for reappointment of Active and Courtesy Staff L, M, N, O, P and Q and Affiliate Staff R, T, V and W revealed the only information available was the information provided by the credentialing verification organization. Interview with the Interim CEO (Chief Executive Officer) on 8/7/13 from 4:15 PM to 4:30 PM and with the Interim CEO and HIM (Health Imformation Management) Manager on 8/8/13 from 8:15 AM to 9:15 AM revealed the following:
- Confirmed that the only information available to the Medical Staff and the Governing Body at the time of reappointment would be the information provided by the credentialing organization;
- No information related to quality and current compentency from Harlan County Health System was available.

Based on observation, record review and staff interview the facility failed to keep an accurate record system to account for and ensure the control of the distribution, use and disposition of the scheduled/controlled medications (classifications of medications based on their "potential for abuse"). The facility census was 2 swing bed and 1 acute care patient.

Findings are:

A. Observations in the Pharmacy with the Pharmacy Technician (Ph T) on 8/6/13 from 2:30 PM to 4:00 PM revealed a locked Cupboard with the current Scheduled Medications, a locked File Cabinet for expired Scheduled Medications and an empty gray locked box on the wall. The Ph T had a book (Count Book) that was used to count the controlled medications. (The Count Book possessed a separate page for each medication with the name of the medication, strength of the medication and the balance of the current medication on hand in the pharmacy.) Random Scheduled Medication counts were completed with the Ph T which revealed:
- Demerol (a narcotic pain medication) 300 mg (milligrams) 30 ml (milliliter) vials in boxes for PCA (Patient Controlled Analgesia) pump. The Count Book showed a balance of 0; the Cupboard had 0 vials; the File Cabinet had 10 outdated boxes, with a balance of 10 extra boxes not being accounted for on the Count Book sheet.
- Xanax (an antianxiety medication) 0.25 mg tablets. The Count Book showed a balance of 160 (with a sticky note dated 11/21/12 - 100 unexpired 11/30/12 in File Cabinet); the Cupboard had 80 tablets; the File Cabinet had 100 outdated tablets, with a balance of 20 extra tablets not being accounted for on the Count Book sheet.
- Fentanyl Transdermal System Patches (a narcotic pain medication) 12 mcg (micrograms)/ hr [hour]. The Count Book showed a balance of 10 (with a sticky note that said 10 expired); the Cupboard had 5 patches; the File Cabinet had 9 outdated patches, with a balance of 4 extra patches not being accounted for on the Count Book sheet.
- Fentanyl Transdermal System Patches 25 mcg/hr. The Count Book showed a balance of 5; the Cupboard had 5 patches; the File Cabinet had 1 outdated patch, with a balance of 1 extra patch not being accounted for on the Count Book sheet.
- Fentanyl Transdermal System Patches 75 mcg/hr. The Count Book showed a balance of 10 (with a sticky note that said 5 expired); the Cupboard had 5 patches; the File Cabinet had 4 outdated patches, with a balance of 1 patch not being accounted for on the Count Book sheet.
- Ativan (an antianxiety medication) 0.5 mg tablets. The Count Book showed a balance of 90; the Cupboard had 90 tablets; the File Cabinet had 19 outdated tablets, with a balance of 19 extra tablets not being accounted for on the Count Book sheet.
- Phenergan with Codeine (a cough medication with a narcotic) elixir 6.25 mg/10mg/5 ml (Phenergan 6.25 mg with Codeine 10 mg per 5 ml) in 118 ml bottles. The Count Book showed a balance of 2-118 ml bottles (with a sticky note dated 6/30/13, 2-118 ml expired); the Cupboard had 0; the File Cabinet had 5-118 ml bottles that were outdated, with a balance of 3 extra 118 ml bottles not being accounted for on the Count Book sheet.
- Tylenol with Codeine (Tylenol with a narcotic pain medication) 300 mg/30 mg (Tylenol 300 mg with 30 mg Codeine). The Count Book showed a balance of 160 tablets; the Cupboard had 160 tablets; the File Cabinet had 19 outdated tablets, with a balance of 19 extra tablets not being accounted for on the Count Book sheet.
- Valium (an antianxiety medication) 2 mg tablets. The Count Book showed a balance of 150 tablets (with a sticky note dated 7/30/13 - 70 expired); the Cupboard had 80 tablets; the File Cabinet had 87 outdated tablets, with a balance of 17 extra tablets not being accounted for on the Count Book sheet.
- Morphine Sulfate (a narcotic pain medication) 30 mg (1 mg/ml - 1 milligram per milliter) vials in boxes for PCA pump. The Count Book showed a balance of 160 boxes; the Cupboard had 150 boxes; the File Cabinet had 16 outdated boxes, with a balance of 6 extra boxes not being accounted for on the Count Book sheet.
- Demerol (a narcotic pain medication) 25mg carpujects (a prefilled cartridge that is loaded into a syringe holder). The Count Book showed a balance of 0 carpujects; the Cupboard had 0 carpujects; the File Cabinet had 15 outdated carpujects, with a balance of 15 extra carpujects not being accounted for on the Count Book sheet.
- Valium (an antianxiety medication) 5 mg tablets. The Count Book showed a balance of 70 tablets (with a sticky note dated 1/31/13 32 expired, 10 from cabinet stock]; the Cupboard had 60 tablets; the File Cabinet had 32 outdated tablets, with a balance of 22 extra tablets not being accounted for on the Count Book sheet.

B. An interview with the Ph T on 8/6/13 at 2:30 PM revealed, " I and another nurse go around and do a weekly cycle count with the Scheduled/Control Medications in the Omnicell (a medication dispensing machine). We got the Omnicell machines a few months ago. We don't really do a count of the scheduled medications in this locked cupboard or the locked file cabinet. I and the Assistant Director of Nurses are the only ones that have access to the keys to the locked cupboard or the locked file cabinet." "We had an old medication dispensing system called the MDG. I think the reason we are long in our counts is that when we changed systems we took the medications out of the MDG and put them in the file cabinet. I didn't continue any kind of count sheet for them. Also, after we owned the Physicians clinic we take their medications that are outdated and needing to be destroyed. So I think that is where they came from..."

C. Interview with the Pharmacist on 8/7/13 at 9:40 AM revealed, "I wasn't aware we were off with the extra medications. I thought we were doing good, we got the Omnicell and I thought it was going good. I think we must of had the "Perfect Storm" in here with the change in staff a few months ago, changing from the MDG system to the Omnicell and the hospital owning the clinic. All those factors played into this, having the extra medications and no count sheet for them. We will get back to the basics and get this resolved immediately."

D. Review of the Controlled Substances policy and procedures dated 4/18/13 and 8/6/13 revealed, "Controlled substances are drugs which are regulated by the Drug Enforcement Administration (DEA) because of potential for abuse. The presence of such drugs on the premises poses a risk of theft or diversion to an unapproved use. An inventory of the controlled substances in the Omnicell system is to be checked and refilled weekly, or as needed. Inventory of the bulk stock of controlled substances is to be checked as needed and recorded as required by federal law."

Based on review of the Quality Improvement Plan. review of the Quality/Risk Management Plan and staff interview, the CAH (Critical Access Hospital) failed to ensure that the quality and appropriateness of diagnosis and treatment furnished by mid-level practitioners (nurse practitioners, clinical nurse specialists and physician assistants) was evaluated by physician member of the CAH medical staff. This failed practice had the potential to affect all patients of the CAH. The inpatient census from August 2012 through July 2013 was 80. On the first day of survey patient census was 1 acute inpatient and 2 skilled/swing-bed inpatients. The roster of Medical Staff provided by the CAH listed 4 PAs (Physician Assistants), 1 APRN (Advance Practice Registered Nurse) and 2 CRNA (Certified Registered Nurse Anesthetists).

Findings are:

A. Review of the Quality Improvement Plan (origin date 7/15/10) and the Quality/Risk Management Plan (origin date 9/21/12) revealed the following under Peer Review "The Medical Staff will implement routine screening criteria to review the quality and appropriateness of diagnosis and management of inpatients and outpatients at Harlan County Health System."

B. Interview with PA (Physician Assistant)-U on 8/7/13 from 12:00 noon until 12:10 PM revealed that job duties included first call in the emergency room, making rounds on the patients in the hospital and writing treatment and medication changes for patients. During this interview the PA indicated that the physician reviews and signs all orders and records completed by the PAs; however, indicated no records were taken to medical staff for peer review.

C. Interview on 8/8/13 at 10:45 AM with the Interim CEO, who was also responsible for quality assurance for the CAH, revealed the physician looks at every mid-level record; however, confirmed that nothing was reported to quality assurance concerning these reviews.

Based on review of the Network agreement with a Nebraska hospital (Network Hospital) for quality assurance, review of the CAH's (Critical Access Hospital's) Quality Improvement Plan, review of the Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines, review of the Performance Improvement Network - Critical Access Hospitals Peer Review Rotation Groups and staff interview, the CAH failed to follow the Network Hospital's plan for review of quality and appropriateness of diagnosis and treatment spelled out in the Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines and failed to follow their own Quality Plan for Peer Review resulting in the lack of review of quality and appropriateness of diagnosis and treatment by physicians at the CAH. This failed practice had the potential to affect all patients of the CAH. The inpatient census from August 2012 through July 2013 was 80. On the first day of survey patient census was 1 acute inpatient and 2 skilled/swing-bed inpatients. The roster of Medical Staff provided by the CAH listed 1 Active Staff, 8 Affiliate Staff and 65 Courtesy Staff.

Findings are:

A. Review of the Network Agreement dated 8/1/2009 under section V (Roman numeral 5) Quality Assurance revealed the following:
"...As necessary, and upon request of QA [Quality Assurance] representatives of Harlan County Health System, the Harlan County Health System Medical Staff, Harlan County Health System Administrator/CEO [Chief Executive Officer], or Harlan County Health System governing body, peer review assistance may be provided by the network's peer review process or another service under contract..."

Review of the Quality Improvement Plan (effective date 9/8/2010) revealed the following concerning Peer Review:
"The Medical Staff will implement routine screening criteria to review the quality and appropriateness of diagnosis and management of inpatients and outpatients at Harlan County Health System. Harlan County Health System will work with the Critical Access Hospital Network in conjunction with [name of Network Hospital] to complete the peer Review Process. Copies of the current screening criteria utilized by the Medical Staff are appended to this document. Medical Staff will conduct reviews of an episodic nature (as documented by Incident Reporting Forms), generic quality screen failures, adverse findings of the QIO [Quality Improvement Organization], requests from other committees, review of benchmarked data from outside sources, requests from the Board of Trustees, and requests from other departments of the Health System."

(Peer review is the process by which a committee and/or another physician examines the work of a peer and determines whether the physician under review has met accepted standards of care in rendering medical services.)

B. Review of a document titled Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines (dated 10/27/10) provided by the CAH's Interim CEO revealed the following:

"Purpose: The Central Nebraska Critical Access Hospital Network Peer Review Process is a non-bias confidential activity performed by the physicians within the network's critical access hospitals. The peer review process will facilitate safe, timely, effective, efficient and equitable patient centered...outcomes through the identification of opportunities for improving processes and delivery of patient care.

Responsibility and Procedure:
1. Each critical access hospital will have an established quality plan for review of appropriate care and treatment of the patients at their facility....
2. The critical access hospital may use the Central Nebraska Critical Access Hospital Network Internal Peer Review process template or establish their own internal peer review process.
3. Charts that are identified for external peer review will be sent for peer review through the external peer review process utilizing the Central Nebraska Critical Access Hospital External Peer Review process template.
4. Peer Review Rotation schedules will be maintained and distributed to the Critical Access Hospitals by the network hub hospital."

Also provided were documents titled Performance Improvement Network - Critical Access Hospitals Peer Review Rotation Groups. Review of these documents revealed Harlan County Health System was to send record to another CAH on a quarterly basis.

C. Interview with the Interim CEO on 8/7/13 from 4:15 PM to 4:30 PM and with the Interim CEO and the HIM (Health Information Management) Manager on 8/8/13 from 9:25 AM to 10:10 AM revealed the following:
- HIM Manager (hire date of 11/1/12) confirmed that there had been no "Peer Review" since starting position.
- Interim CEO confirmed the CAH had completed no "Peer Review" from June 2012 through November 2012.
- HIM Manager had a Peer Review file and confirmed that the last Peer Review Audit Sheets in that file were from October 2011.
- Interim CEO indicated that about 3 months ago were going to send records to another CAH for Peer Review but the Quality Assurance person from the other CAH indicated their physicians were too busy and no records were sent.
- Interim CEO confirmed that the Network Hospital was not contacted about other CAH not being able to complete Peer Review for Harlan County Health System.

Based on staff interview and record review, the facility failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients due to their level of care or difficulty with their care. This has the potential to effect all Swing Bed Residents. The facility census was 2 Swing Bed patients and 1 Acute Care patient.

Findings are:

A. Interview with the Nurse Case Manager [ CM] 8/8/13 at 11:45 AM confirmed, "No, we don't have an admission, transfers or discharge policy and procedure to cover requirements, documentation, notice, timing of notice and content of notice for Swing Bed patients."

B. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the facility failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients without cause. This has the potential to effect all Swing Bed Residents. The facility census was 2 Swing Bed patients and 1 Acute Care patient.

Findings are:

A. The facility lacked having a policy or procedure with the components related to a facility-initiated discharge or transfer unless:
- The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.
- The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.
- The safety / health of individuals in the facility would be endangered.
- The resident has failed, after reasonable and appropriate notice to pay for a stay at the facility.
- The facility ceases to operate.

B. Interview with the Nurse Case Manager (CM) 8/8/13 at 11:45 AM confirmed, "No, we don't have an admission, transfers or discharge policy and procedure to cover requirements, documentation, notice, timing of notice and content of notice for Swing Bed patients."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the facility failed to have a Policy and Procedure in place to ensure the physician completes the required documentation of a facility-initiated transfer and discharge. This has the potential to effect all Swing Bed Residents. The facility census was 2 Swing Bed patients and 1 Acute Care patient.

Findings are:

A.The facility lacked having a policy or procedure with the necessary components outlining the documentation requirements for a facility-initiated transfer or discharge including:
- The Physician's documentation in the patient's record related to the necessity of transfer and discharge.

B. Interview with the Nurse Case Manager [ CM] 8/8/13 at 11:45 AM confirmed, "No, we don't have an admission, transfers or discharge policy and procedure to cover requirements, documentation, notice, timing of notice and content of notice for Swing Bed patients."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the Critical Access Hospital could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the facility failed to have a Policy and Procedure in place to ensure proper procedures for notification of transfers. This has the potential to effect all Swing Bed Residents. The facility census was 2 Swing Bed patients and 1 Acute Care patient.

Findings are:

A. The facility lacked having a policy or procedure with the necessary components related to notification of facility-initiated transfers and discharges including:
- The resident, a family member or legal representative was provided a notice of the transfer or discharge and with the reasons for the move in writing in a language they understand.
- They record the reasons in the resident clinical record.

B. Interview with the Nurse Case Manager (CM) 8/8/13 at 11:45 AM confirmed, "No, we don't have an admission, transfers or discharge policy and procedure to cover requirements, documentation, notice, timing of notice and content of notice for Swing Bed patients."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on review of personnel files, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to check the State Nurse Aide Registry prior to hiring 1 of 2 Ward Clerks/NAs (Nursing Assistants) reviewed. The CAH had hired 2 Ward Clerks in the last year and had a total of 10 Ward Clerks/NAs on staff. This failed practice had the potential to affect all patients of the CAH. The inpatient census from August 2012 through July 2013 was 80. On the first day of survey patient census was 1 acute inpatient and 2 skilled/swing-bed inpatients.

A. Review of the personnel file for Ward Clerk-E with a hire date of 10/1/12 revealed no evidence that the State NA registry was checked.

Interview with the Interim CEO on 8/6/13 from 3:50 PM to 4:15 PM after looking through the personnel file for Ward Clerk-E confirmed the file lacked evidence that the Nebraska NA Registry was checked.

B. Review of the policy and procedure titled Background Checks & Post Offer (effective date 2/13/13) revealed the following:
"Upon extending a contingent offer of employment to any person, the pending new hire will be required to authorize and participate in several post-offer assessments to include...Nurse Aide Registry - if applicable...."
Under the section titled Procedure, human resources was directed to "verify the pending new hires licensure and certifications required for the position and as defined in the job description in accordance with the applicable policy...State Nurse Aide Registry...Any new hire in a position which requires a certified nurse aide or any position that assists patients, will have their record checked with the State Nurse Aide Registry. A copy of this verification placed in the new hire file."