HospitalInspections.org

Based on document review and interview, 3 of 4 (Staff A - Staff C) new graduate respiratory therapists (RT) did not have a limited permit or license to practice prior to providing patient care. This could lead to untoward patient outcomes.

Findings include:

-- Per review of the New York State Office of the Professions, Division of Professional Licensing Service, Respiratory Therapy limited permit application "The applicant may not practice respiratory therapy until the limited permit is issued."

-- Review of the facility's job description for a Respiratory Therapist (last revised 10/2016) stated "Minimum Requirements; Minimum Education/Certification/Licensure Required; Current New York State License as a Respiratory Therapist and credentialed by the National Board for Respiratory Care (NBRC) as a Registered Respiratory Therapist."

-- Per review of Staff A, RT personnel file, he/she did not have a Respiratory Therapy limited permit or license to practice. The same lack of a limited permit or license was evident in Staff B's, RT and Staff C's, RT personnel files.

-- Per interview of Staff D, RT on 10/3/19 at 8:47 am, he/she did not apply for a temporary permit because he/she was told there was not time before taking the licensure exam.

-- Per interview of Staff A, on 10/3/19 at 9:04 am, he/she did not have a current permit because prior to being hired, he/she had already completed the first of two licensure exams.

-- Per interview of Staff E, Respiratory Services Manager and Staff F, Administrative Director Medical Imaging, Physical Medicine & Rehabilitation, Respiratory, Neurophysiology and Sleep Services, on 10/3/19 at 9:00 am, the new graduate RT staff were treated as students so they did not think limited permits were necessary.

-- During interview of Staff G, Director Human Resources, on 10/3/19 at 2:40 pm, he/she acknowledged the above finding and indicated the new graduate hires did not have a temporary permit or a license when hired.