HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 non-licensed personnel files (E#5 and E#14) reviewed for background checks, the Hospital failed to ensure that patients were free from abuse by not screening non-licensed personnel for records of abuse.

Findings include:

1. The Hospital's policy titled, "Employment Requirement" (revised August 2019), was reviewed on 11/29/2022 and required, "...Background Checks/Screenings - Employment is subject to satisfactory completion of: ...Healthcare Workers background check..."

2. The personnel files of 2 Mental Health Counselors (non-licensed - E#5 and E#14), were reviewed on 11/29/2022.
- E#5's date of hire was 10/10/2022 (per the Vice President of Human Resources/E#15). E#5's personnel file lacked a health care worker registry check, as required.
- E#14's date of hire was 10/10/2022. E#14's personnel file lacked a health care worker registry check, as required.

3. During an observational tour of the 3A Adult Behavioral Health Unit on 11/28/2022, between approximately 10:30 AM and 12:00 PM, both E#5 and E#14 were present and working with patients on the unit.

4. An interview was conducted with the Vice President of Human Resources (E#15) on 11/29/2022, at approximately 12:30 PM. E#15 stated that they run the HCWR check on PCTs (Patient Care Technicians), MAs (Medical Assistants), and CNAs (Certified Nursing Assistants) during onboarding. E#15 stated that this check was not being done for MHCs and stated that going forward they will make sure to include MHCs.