HospitalInspections.org

Based on review of personnel records and facility policy, and staff interview, it was determined the facility failed to implement their abuse prevention policy for level 2 background screenings prior to the date of employment for two (2) out of ten (10) sampled staff personnel records reviewed (Staff #9 and #13), as evidenced by background screen results documented as obtained by the facility 25 days after the hire date of Staff #9 and 4 months after the hire date of Staff #13.

The finding includes:

An interview and personnel record review was conducted on 4/03/14 at 3:00 PM with the Human Resources Coordinator. The review included ten (10) personnel records and revealed Staff #9, and # 13, who have direct patient contact, did not have a documented level 2 background screen (BGS) prior to their first day of work in the facility.
The following evidence was obtained:
? Staff #9 was hired as a registered nurse on 3/10/2008. The personnel record indicates the level 2 BGS was completed on 4/04/2008, 25 days after Staff #9 was hired and had contact with patients and their medical records.
? Staff #13 was hired as a mental health technician on 1/17/2006. The personnel record indicates the level 2 BGS was completed on 5/18/2006, four (4) months and one day after the date of hire.
The Human Resource Coordinator acknowledged that Staff #9 and #13 did not have a documented level 2 background screen prior to their first day of work, at which time they had contact with patients and their confidential medical records.
Review of the facility policy concerning background screenings before hire indicates on page #2, line 1, section "A" the following: "All employees will be fingerprinted and undergo a level 2 criminal history background screening during the pre-employment process prior to their first day of work and again for re-screening every 5 years thereafter."