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Based on interview and review of the facility personnel files, the facility failed to obtain a new Level 2 Agency for Health Care background screen, post the 5 year required expiration date for 1 of 5 employees reviewed. (D)

Findings:

Review of the personnel file for Employee D, a Registered Nurse, revealed a date of hire of 8/14/06. The employee was assigned a working schedule and was working on in the Children's unit during the survey. Employee D's personnel file showed an eligible Level 2 Agency for Health Care Level 2 Background screen that documented it was completed on 4/14/2016 with an expiration date of 4/14/21. A new post 5 year background screen was not observed in the file.

A search of the AHCA Background screening unit information via computer was performed on 7/13/21 and showed documentation of the employee's name, and the statement "Agency Review Required." There was no documentation observed of an Eligible determination and showed: "Agency Review Required."

On 7/13/21 at 3:50 PM the facility Risk Manager, (RM) verified the findings and contacted the AHCA background screening unit . The RM related she was informed by the background screening unit that the provider needed to initiate an "Agency Review "with the AHCA screening unit and upon that time, eligibility determination of the background screen for Employee D could take 5 to 7 days .

The hospital behavioral health staffing schedule was reviewed with the Assistant nurse manager and the RM, which showed employee D had been working in the facility past the required background screen expiration date of 4/14/21. They related employee D was a full-time employee and had a regularly scheduled assignment.