HospitalInspections.org

Based on review of facility documents, personnel files (PF), and credential files (CF), and staff interviews (EMP), it was determined that the facility failed to comply with the Child Protective Services Law and with regulations promulgated there under by the Department of Public Welfare for two of eleven personnel files (PF7 and PF11).

Findings include:

Review of 23 Pa. CSA ?6344 revealed, "For the purposes of this subsection, an applicant may submit a copy of the information required under paragraphs (1) and (2) with an application for employment. Administrators shall maintain a copy of the required information and shall require applicants to produce the original document prior to employment ..."

Review of the November 200,8 "Notice to Facilities on Required Employment Clearance,s" revealed, "To assure compliance with the requirements of the Law, facilities must ... -Retain a copy of each of the background clearances and notate that the original documents have been reviewed ..."

Review, on December 11, 2013, at approximately 2:50 PM, of Administration policy, "Criminal Background Check," originating March 2004 and revised December 2011, revealed, "1. All applicants must complete an application for Edgewood Surgical Hospital. 2. The application must be signed by the applicant permitting the performance of a criminal background check by the hospital. 3. As part of the application process the hospital will perform a criminal background check on all employees that have the potential to have any contact with patients prior to hiring. 4. The Hospital will utilize PATCH website for conduction [sic] criminal background checks operated by the Pennsylvania State Police. 5. The Hospital will utilize the DPW Childline Services to complete the child abuse history clearance. 6. The Hospital will utilize Cogent Systems to conduct the fingerprint based national criminal history records checks ... 8. All criminal background checks will be reviewed by Administration prior to hiring ..."

1. Further review, on December 11, 2013, at approximately 2:50 PM, of Administration policy, "Criminal Background Check," originating March 2004 and revised December 2011, failed to reveal how the facility would prove that the results of the original background clearance was viewed by facility staff prior to a copy of the clearance being placed in the employee's personnel file; and failed to require the information to be documented in the personnel files.

2. Review of PF7 and PF11 on December 10 and 11, 2013, at approximately 2:45 PM and 9:00 AM respectively, revealed copies of the Cogent background checks without notation of who viewed the originals, or if they were viewed.

3. Interview with EMP1 on December 10 and 11, 2013, at approximately 2:45 PM and 9:45 AM respectively, confirmed the policy did not require documentation of the criminal background checks in the files, did not require the notation of viewing the original documents, and the files listed did not include notations.