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Based on record review and interview the facility failed to ensure compliance with all applicable state laws.

Findings include:

The Facility failed to ensure that all personnel complied with applicable State laws.

Cross Reference to A-0023

Based on file review and interview, the facility failed to ensure that all personnel who are required by State law (RSA 326-B:2 X) and Federal regulations to have a current license for 1 of 12 personnel reviewed.

Findings include:

A complaint survey was conducted on 7/24/17. During this investigation a request was made of the facility to provide a list of licensed nurses. A sample of 12 personnel files were selected, one of the sampled licensed personnel was Staff A, CNO (Chief Nursing Officer). The documentation provided by the facility identified Staff A on the list of "Nursing Licenses"dated 7/24/2017 with a "position code" listed as "Chief Nursing Officer" and a "license code" indicating Staff A as "Lic-Regst Nurse (RN)". The document also indicates that Staff A's license expiration date was 11/16/17. Review of the personnel file for Staff A provided neither documented evidence of a criminal background check (RSA 151:2-d Criminal Record Check Required) nor evidence of a current nursing licence. Interview at exit on 7/24/17 with Staff A confirmed that Staff A did not have a current licence

Based on interview and record review the facility CEO (Chief Executive Officer) failed to manage all daily operations of the facility in a way to maintain compliance with all State and Federal laws, rules and regulations.

Findings include:

During a complaint survey on 7/24/17 it was identified that Staff B (Chief Executive Officer) had hired Staff A CNO (Chief Nursing Officer) into a position that by State law and Federal regulation required a current nursing license and did hire Staff A with the knowledge that Staff A did not possess an active license. The job description titled "Chief Nursing Officer" dated 5/30/17 that was in place at the time of hire was in violation of both State law and Federal Regulation in regards to the waiving of the license requirement for one year after hiring. Staff B allowed Staff A to serve in a senior nursing position and take part in nursing activities, such as, but not limited to endorsing of policy and procedures and the advising of senior management on nursing matters from 11/16/16 to 7/24/17.

Evidence gathered from facility provided materials indicate that senior management either knew or should have known, based on regulatory requirements, that the position of CNO needed to be held by a licensed nurse. Interview with Staff B at exit on 7/24/17 identified that the expired licensure status of Staff A was known and that legal advice was given that was contrary to State law and Federal regulations.

Based on record review and interview the facility failed to ensure that the nursing services that were furnished were supervised by an individual who meets the definition of a registered nurse in the state of New Hampshire in that they did not hold a current nursing license to practice in this State

Findings include:

During a complaint survey on 7/24/17 the personnel files for 12 employees who were listed as Registered Nurses were reviewed to confirm required licensure. During this review it was identified in the file for Staff A (Chief Nursing Officer) that there was no documented evidence that Staff A was licensed in the State of New Hampshire. Interview at exit on 7/24/17 with Staff A confirmed the above finding and that Staff A's last license was from the state of Maine and had expired in 2005.

Cross Reference to A-386 and A-394

Based on document review and interview it was determined that the facility failed to ensure that based on the plan of administrative authority and the delineation of nursing responsibilities that the individual responsible for the oversight of patient care was a licensed Registered Nurse.

Findings Include:

Review on 7/24/17 of the "Chief Nursing Officer" job description dated 5/30/17 identifies that the Chief Nursing Officer (CNO) is "charged with ensuring that patient-care, clinical and staffing standards are met". In addition the CNO "advises senior management on best practices in nursing and patient care", and establishes "nursing policies and procedures". In order to carry out these duties the CNO would have to be by law and regulation a licensed Registered nurse.

Review of the organization chart ("Leadership Reporting Structure") as provided by the facility, identified Staff A as an RN (Registered Nurse). Review of the signature sheet for the "POLICY COMMITTEE" under "Approved by" identified Staff A as the CNO and as an RN. Review of the personnel file for Staff A showed no documented evidence of a current nursing license. A phone interview on 7/21/17 with the New Hampshire Board of Nursing, as well as interview with Staff A at exit, confirmed that Staff A did not have a current nursing license.

Based on document review and interview the facility failed to ensure that all nursing personnel for whom licensure is required have a current license

Findings include:

Review of facility documents revealed the Chief Nursing Officer (CNO) job description identifies that the educational baseline for this position is that the candidate be an RN (Registered Nurse) , with varying experience criteria, and the"Leadership Reporting Structure" indicates that Staff A CNO (Chief Nursing Officer) is an RN. In addition the company website as of the day of survey (7/24/17) identified Staff A as an RN.

Review of State law RSA 151 Section 326-B:2 paragraph X states a "Registered Nurse" or "RN" means an individual who holds a current license to practice registered nursing..."

Review of the personnel file for Staff A revealed no documented evidence of a current nursing license. Interview with Staff A on 7/24/17 confirmed that they did not have a current license.