HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 non-licensed personnel files (E #5, E #18) 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. On 9/8/2022, a policy on the screening of non-licensed personnel for abuse through the Illinois Department of Public Health - Health Care Worker Registry (HCWR) for the Hospital was requested. No policy was presented.

2. On 9/8/2022, email communication from the Hospital's Human Resource department was presented, and included, "State Specific BG [background] Check Process: All non-licensed employees must complete a Health Care Worker Background Check through IDPH..."

3. The personnel files of 2 Certified Nursing Assistants (non-licensed - E #5 and E #18), were reviewed on 9/8/2022.
- E #5's date of hire was 8/16/2004. E #5's initial background was ran through IDPH's HCWR on 6/30/2004. The last HCWR check, prior to 9/7/2022, for E #5, was done on 6/21/2013. The personnel files lacked subsequent annual registry checks, as required.

- E #18's date of hire was 3/27/2017. E #18's initial background was ran through IDPH's HCWR on 8/30/2021. A subsequent HCWR check was done 9/7/2022. The personnel files lacked an initial and annual registry checks, as required.

4. On 9/8/2022 at 2:30 PM, an interview was conducted with the Chief Clinical Officer (E #19). E #19 stated that she was not aware that the employees have to be ran through the HCWR annually. E #19 reviewed and acknowledged that E #5 and E #18's file lacked the required HCWR checks.

5. A telephone interview was conducted with the Human Resorces Specialist (E#21) on 9/8/2022, at approximately 2:50 PM. E#21 stated that the the HCWR check should be completed upon hire and annually for non-licensed personnel.