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Based on record review and interview, the governing body failed to ensure that a contractor of services furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This deficient practice was evidenced by the failure to complete pre-employment criminal background checks by an approved Louisiana State Police Authorized Agency, pursuant Louisiana Revised Statues (La. R.S.) and Hospital State Regulations on 8 (S1APOA - S8APOA) of 8 (S1APOA - S8APOA) personnel files reviewed.
Findings:

Pursuant to La. R.S. 40:1203.1-5, Licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual.

Pursuant to La. R.S. 40:2179 and 2179.1, "Non-licensed person" means any person who provides for compensation nursing care or other health-related services directly related to patient care to residents in or patients of a nursing facility, intermediate care facility for people with developmental disabilities, adult residential care facility or provider, pediatric day healthcare facility, adult day healthcare center, psychiatric residential treatment facility, end stage renal disease facility, behavioral health services provider, home health agency, hospice agency, provider of ambulance services, hospital, adult brain injury facility, crisis receiving center, pain management clinic, outpatient abortion facility, rural health clinic, ambulatory surgical center, therapeutic group home, forensic supervised transitional residential and aftercare facility, case management provider, or home- and community-based service provider and who is not a licensed health provider. "Non-licensed person" also means any person who provides such services to individuals in their own homes as an employee or contract provider of a home health agency, hospice, or home- and community-based service provider.

Pursuant to La. R.S. 15:575, The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State's designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2.

Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the La. Secretary of State's office. Authorized Agents must also be certified by the Bureau. Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State's office and the Bureau are not authorized to request or receive criminal history information stored in LACCH.

A personnel file review of S1APOA - S2APOA revealed pre-employment criminal background checks completed for each of the before mentioned personnel by Company A. A review of the list of approved Louisiana State Police Authorized Agencies did not reveal Company A.

In an interview on 04/09/2025 at 3:40 PM, S2VP confirmed the above mentioned findings and confirmed the facility should be using an approved state police authorized agency.