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Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined that the governing body failed to ensure the facility maintained an effective audit tool for clinical staff to ensure staff licenses remain valid.

Cross reference to A0063 as it relates to the governing body's failure to ensure licensed staffed to provide care of patients.

Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined the facility failed to ensure for seven (7) of seven (7) (P#1, P#2, P#3, P#4, P#5, P#6, P#7) sampled patients, a licensed registered nurse provided discharge planning.

Cross reference to A-0063 as it relates to RN AA failing to have an active nursing license.

Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined the facility failed to ensure for seven (7) of seven (7) (P#1, P#2, P#3, P#4, P#5, P#6, P#7) sampled patients, a licensed registered nurse provided discharge planning.

Cross reference to A-0063 as it relates to RN AA providing discharge planning servises dispite having an inactive nursing.

Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined that the governing body failed to ensure the facility maintained an effective audit tool for clinical staff to ensure staff licenses remain valid.

Cross reference to A0063 as it relates to the care of patients.

Findings include:

A review of the Hiring-Employment Procedures policy, policy number HR.22, no effective date, no revision date, revealed the purpose is to ensure that all qualified candidates for employment are properly identified and to provide the process for hiring qualified individuals to fill positions at Landmark. Further review revealed the Human Resources Department is responsible for the hiring process in coordination with the department manager. Human Resources is responsible for securing all reference checks, license verification (if necessary), and criminal background checks.

A review of the Discharge Planning policy, policy number DP-04, effective 10/15/14, reviewed 4/2021 revealed all patients admitted to Landmark Hospital will receive an initial screening to identify potential need for discharge services during the admission assessment conducted by the admitting nurse withing the first (8) hours of admission. Changes in the patient's condition during hospitalization may warrant development of a discharge plan for a patient not identified during the initial screening process. In these situations, a referral shall be made within 24 hour of identification to staff qualified to perform a discharge planning evaluation. The discharge planning evaluation shall be performed by qualified personnel with a knowledge of clinical, functional status, social, insurance/financial and physical factors that must be considered when evaluating how a patient' expected post-discharge care needs can be met. In addition, knowledge of community resources to meet post-discharge clinical and social needs. The following are considered qualified personnel: Nurse Case Managers, Social Workers, and Registered Nurses with previous experience in discharge planning.


A review of the Case Manager job description summary revealed the Case Manager is responsible for coordination of the patient's plan of care and the resources utilized for the patient's stay. Scope of the case management process involves assessment, planning, negotiating, coordinating, monitoring, evaluating options and services and reporting to meet the health needs of the individual patient. Coordinates patient care with the transdisciplinary team during the episode of illness and facilitates discharge within the expected length of stay. Ensures that specific patient outcomes are achieved and that variances are evaluated and addressed in collaboration with members of the healthcare team. Assists in clinical outcomes data collection. Coordinated and oversees the Utilization Review Committee and performs concurrent utilization review as defined in the Utilization Review Plan. Effectively communicates utilization review findings with the transdisciplinary team to assist in facilitating an appropriate continued stay or discharge. Further review revealed RN license in State if Registered Nurse is a requirement.


A review of the Registered Nurse job description summary revealed the Registered Nurse operates within Landmark Hospital's Core values to provide in-depth clinical expertise in nursing practice. As a Registered Nurse, you will be responsible for the assessing, planning, delivery and evaluating each level of nursing care provided to patients throughout their stay. You will also actively plan for the management of patient outcomes across the continuum of care. This will require that you work in close cooperation with specialists in a variety of disciplines, including (but not limited to) Physicians Pharmacists, Physical Therapy, Occupational Therapy, Respiratory Therapy, Wound Care, Dietary Therapy, Social Work and Dialysis. Further review revealed a valid RN license in state is a requirement.

Review of Professional Licensing on the Georgia Secretary of State website revealed RN AA's registered professional nurse license expired 1/31/2020

Review of Signed Job Description for Case Manager revealed job description was signed by RN AA and dated 12/21/17

Review of current and terminated nursing staff list from 2019 through 2021 revealed RN AA was not included on the current nursing staff list.

Review of Human Resources (HR) 2022 Audit Tool used by HR Manager to manage clinical staff licenses revealed the following licenses will expire 1/31/22: 1-Chief Clinical Officer and 4-Registered Nurses. Continued review revealed the following licenses with expire 3/31/22: 3-Respiratory Therapists, 1-Dietician, 2-Occupational Therapist, and 1-Licensed Practical Nurse.

A review of Patient (P)#1's medical record revealed RN AA completed a Case Management Wound Care Criteria Assessment that was signed and dated on 7/7/21. Further review revealed the assessment included the following indicators: clinical indications, infected surgical or non-surgical wounds, concurrent medical condition, and treatment criteria.

A review of P#2's medical record revealed RN AA completed a Case Management Complex Medical Criteria Assessment that was signed and dated on 8/10/21. Further review revealed the assessment included the following indicators: acute Musculo-skeletal disorder, acute cardiac dysfunction, any acute complications following surgery, gastrointestinal dysfunction, hematologic/oncologic disorders, and wound management.

A review of P#3's medical record revealed RN AA completed a Case Management Wound Care Criteria Assessment that was signed and dated on 9/11/21. Further review revealed the assessment included the following indicators: thickness of wounds, infected surgical or non-surgical wounds, concurrent medical condition, and treatment criteria. Continued review of the medical record revealed RN AA completed a Case Management Progress Note that was signed and dated on 9/28/21.

A review of P#4's medical record revealed RN AA completed a Case Management Initial Assessment that was signed and dated on 1/11/22. Further review revealed RN AA completed a Case Management Respiratory Therapy Assessment signed and dated 1/11/22. Continued review revealed the assessment included the following indicators: ventilator dependent, respiratory insufficiency, treatment criteria, IV Medications, mechanical ventilation, and alternative criteria.

A review of P#5's medical record revealed RN AA completed 3 Case Management Wound Care Assessment that were signed and dated on 7/7/21, 7/14/21, and 7/23/21. Further review revealed the assessments included the following indicators thickness of wounds, infected surgical or non-surgical wounds, wounds, concurrent medical condition, and treatment criteria. Continued review revealed RN AA completed a Case Management Progress Note Assessment that was signed and dated on 7/20/21.

A review of P#6's medical record revealed RN AA completed 2 Case Management Complex Medical Assessments that were signed and dated on 6/28/21 and 7/7/21. Further review revealed the assessments included the following indicators acute Musculo-skeletal disorder, acute cardiac dysfunction, gastrointestinal dysfunction, hematologic/oncologic disorders, post-acute neurological disorders, renal disorders, IV medications, pulmonary hygiene and/or secretion management, PT, OT, and/or ST, and wound management.

A review of P#7's medical record revealed RN AA completed 2 Case Management Respiratory Therapy Complex Assessments that were signed and dated on 9/14/21, and 9/22/21. Further review revealed the assessments included the following indicators respiratory insufficiency, post ventilator weaning, pneumonia requiring respiratory assessment and intervention, treatment criteria, and rehabilitation services. Continued review revealed RN AA completed a Case Management Progress Note that was signed and dated on 9/23/21 and 9/28/21. Continued review revealed RN AA completed a Case Management Initial Assessment that was signed and dated on 9/15/21.

An interview with Human Resources (HR) Manager (HR FF) on 1/11/22 at 1:45 pm in the conference room revealed she was promoted to HR Manager two weeks ago and her responsibilities include new hire on-boarding, checking for licensure, background checks, compiling the personnel files, and payroll. HR FF stated that she is currently still training with the Regional HR Director who currently works at another facility in Athens. She continued to state apart of her responsibility will be to maintain an on-going spreadsheet in order to keep up with the staff licenses and expiration dates. HR FF stated she has not received a copy of the spreadsheet from HR II yet but states it will become a part of her training. She continued to state that there is no HR policy regarding the responsibility of on-going license verification.

An interview with Chief Clinical Officer (CCO) on 1/11/22 at 2:00 pm in the conference room revealed her responsibilities include being over all the clinical departments at the facility. She continued to state that she does all the hiring for the clinical staff, including therapy and excluding case management. CCO continued to state she is responsible for maintaining continuing education for her staff as well as the weekly scheduling. She continued to state she also keeps up with quality metrics and auditing including monitoring hourly rounding. CCO continued to state human resources (HR) maintains the licensing roster for the nursing staff and HR would let her know when a nurse's license is soon to expire. CCO continued to state that the Case Management Department does not fall under her responsibility. She stated Case Management reports directly to the Chief Executive Officer (CEO). CCO continued to state she was not made aware of the expired license for RN AA as she is a RN Case Manager who reports directly to the CEO.

An interview with Case Manager (RN AA) on 1/11/22 at 3:30 pm in the conference room revealed she works in the Case management Department as a nurse case manager. She stated she is responsible for patient placement to rehabilitation facilities, nursing, home placement, referrals to home health agencies, discharging patients to home or another appropriate setting. RN AA continued to state she participates in the interdisciplinary team (a group of health care professionals with various areas of expertise who work together toward the goals of their clients) (IDT) meetings to discuss current patients, their diagnosis', any barriers to discharge, and plan to discharge. RN AA continued to state that she has no contact with patients at their bedside. She continued to state when she realized that her license was expired she went onto the Georgia Secretary of State website on the 21st of December to renew her license and started the process and sent in all the paperwork. She continued to state that as of December 21 her license has been pending reinstatement. RN AA stated she realizes her license expired 1/31/2020 and stated she submitted a notarized letter to the Secretary of State explaining what happened.

An interview with HR FF on 1/12/22 at 9:45 am in the conference room revealed after reviewing the personnel file for RN AA she confirmed her licensed had expired on 1/31/20. HR FF stated that RN AA advised her today that her license is currently pending renewal.

An interview with the CEO on 1/12/22 at 11:00 a.m. in the conference room revealed he was made aware from his staff that the RN Case Manager was working at the facility since 2020 with an expired nursing licensed. He continued to state he notified his corporate office of the issue and put processes in place to correct the issue. CEO continued to state the expired registered nurse's (RN) licensed was something he should have been made aware of and the management staff has learned from this experience.

During a phone interview with Regional HR Director (HR II) on 1/12/22 at 1:00 p.m. revealed she works full-time at Landmark Hospital Athens in Athens and is currently training the new HR Manager at Landmark Hospital. She continued to state when new-hires go through on-boarding (the action or process of integrating a new employee into an organization) any relevant licensing is verified and added to the HR spreadsheet. She continued to state it is her responsibility to update and monitor the spreadsheet for upcoming license expirations. She continued to state she is in the process of training the HR Manager on this process. HR II further stated the facility incorporated a new HR process three months ago to maintain up-to-date statuses on valid nursing licenses. She continued to explain that the new process includes a new payroll system that will notify the employee and HR staff when a license is due for renewal. HR II continued to explain prior to the new payroll system keeping track, the HR staff utilized a different payroll system to keep track as well and it was with the older system RN AA's license expiration was overlooked. She continued to state RN AA's license states "pending" on the Secretary of State's website. HR II acknowledged that RN AA's license did expire on 1/31/2020 and that RN AA should not have been allowed to work in a nursing capacity until her nursing license was successfully renewed.

Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined the facility failed to ensure for seven (7) of seven (7) (P#1, P#2, P#3, P#4, P#5, P#6, P#7) sampled patients, a licensed registered nurse provided discharge planning.

Cross reference to A-0063 as it relates to RN AA failing to have an active nursing license.

Based on review of governing body bylaws, staff interviews, medical record reviews, and facility job description requirements, it was determined the facility failed to ensure for seven (7) of seven (7) (P#1, P#2, P#3, P#4, P#5, P#6, P#7) sampled patients, a licensed registered nurse provided discharge planning.

Cross reference to A-0063 as it relates to RN AA providing discharge planning servises dispite having an inactive nursing.