cms_WV: 832
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 832 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2018-05-17 | 607 | L | 1 | 1 | H2ZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify fourteen (14) of fifteen (15) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure fourteen (14) of the fifteen (15) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of three (3) Licensed Practical Nurses (LPNs) and eleven (11) nurse aides (NAs). This practice had the potential to affect all residents residing in the facility. Notice of the Immediate Jeopardy (IJ) was given to the Center Executive Director (CED) on 05/17/18 at 5:15 PM. An acceptable plan of correction (P[NAME]) was received from the CED on 05/17/18 at 7:00 PM. After verification of the implementation of the plan of correction, the immediate jeopardy was abated at 7:00 PM. Employee identifiers: #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #72. Facility census: 111. Findings included: a) On 05/17/18 at 12:50 PM, a review of employee background checks with Human Resources Manager (HRM) #20 revealed the facility had employed 15 agency employees. Three (3) of the agency employees were LPNs and eleven (11) were nurse aides (NAs). HRM #20 said she would locate the background checks for the agency employees. According to the facility's records, the employees provided by an agency began working in the facility on the following dates: - LPN #58 - 01/03/18 (the start date was listed at 01/03/18, but when the facility printed the work history she had worked in (MONTH) (YEAR)) - NA #59 - 03/19/18 - NA #60 - 03/26/18 - NA #61 - 03/28/18 - NA #62 - 04/02/18 - LPN #63 - 04/02/18 - NA #64 - 04/04/18 - NA #65 - 04/09/18 - NA #66 - 04/09/18 - NA #67 - 04/09/18 - NA #68 - 04/15/18 - NA #69 - 04/15/18 - NA #70 - 04/15/18 - LPN #71 - 04/30/18 (This was the only agency person for which the facility had a letter from WV CARES) - LPN #72 - 05/07/18 Review of when the agency staff had worked since their hire dates found the following. - NA #60 had worked 42 days between 03/27/18 and 05/17/18. - LPN #58 had worked 86 days between 10/16/17 and 05/17/18. - NA #59 had worked 38 days between 03/19/18 and 05/17/18. - NA #61 had worked 29 days between 03/28/18 and 05/17/18. - NA #62 had worked 35 days between 04/02/18 and 05/17/18. - LPN #63 had worked 27 days between 04/02/18 and 05/17/17. - NA #64 had worked 34 days between 04/04/18 and 05/17/18. - NA #65 had worked 23 days between 04/09/18 and 05/17/18. - NA #66 had worked 27 days between the dates of 04/09/18 and 05/17/18. - NA #67 had worked 28 days between 04/10/18 and 05/17/18. - NA #68 had worked 23 days between 04/15/18 and 05/17/18. - NA #70 had worked 13 days between 04/15/18 and 05/17/18. - LPN #72 had worked 2 days between 05/13/18 and 05/17/18. On 05/17/18 at 6:20 PM, the CED and HRM #20 could not provide any information on the background checks for the listed employees. They said these individuals were employed by an agency and they were under the impression the agency had checked the criminal backgrounds prior to them coming to work at their facility. They verified they had not checked to make sure the agency had in fact completed the background checks with the WV CARES system prior to employees working in the building. (Note: WVCARES does the state/federal background checks and all registry checks for the facility.) On 05/17/18 at 7:09 PM, HRM #20 said she could look in the WV CARES system and see where LPN #72 and NAs #66 and #68 had clearance letters in WV CARES. However, HRM #20 did not know how to find the letters from WV CARES showing these three (3) employees were eligible to work in the facility. The facility only had one (1) agency staff member (LPN #71) who had a letter from WV CARES showing that individual's eligibility to work in the facility. When the Center Executive Director and HRM were asked to provide the clearance letters, for LPN #72 and NA #66 and #68, they could not. HRM said, because she did not enter LPN #72, NA #66 and NA #68 into the WVCARES system, she could not get the letters from WVCARES. The facility was given ample time to contact their agency to get this information, but no further information was forthcoming. The Center Executive Director said they had trusted the agency to do the background checks and they were not done. She said she should not have trusted them instead she should have verified they were done. The employee who hired these agency staff members and who was responsible for this verification no longer worked at the facility. The facility's policy included, The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy.) 2.1 The Center will not employ or otherwise engage individuals who: 2.1.1 Have been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment; or 2.1.2 Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. 2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service will be reported to the state nurse aide registry or licensing authority; 2.1.3 Have had a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED]. The facility's failure to follow its policy, and to obtain or verify background checks were completed through the WVCARES system to determine whether these employees were eligible to work with the nursing home residents, placed all resident of the facility at risk for serious harm. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of three (3) Licensed Practical Nurses (LPNs) and eleven (11) nurse aides (NAs). This practice had the potential to affect all residents residing in the facility. Notice of the Immediate Jeopardy (IJ) was given to the Center Executive Director (CED) on 05/17/18 at 5:15 PM. An acceptable plan of correction (P[NAME]) was received from the CED on 05/17/18 at 7:00 PM. After verification of the implementation of the plan of correction, the immediate jeopardy was abated at 7:00 PM. No deficient practice remained for this requirement after removal of the immediate jeopardy. b) The facility's plan of correction May 17, (YEAR) 6:23pm Administrator immediately removed the identified agency CNA's (2), from the floor at 2:00pm on (MONTH) 12, (YEAR). Staffing was immediately adjusted accordingly to meet resident needs. All residents of the facility have the potential to be effected. No residents of the facility have experienced any negative outcome. A list of all Agency Employee's was immediately compiled by the Human Resources Manager, on (MONTH) 17, (YEAR) at 2:15pm. All Agency Employee's identified were immediately notified by the Administrator/Designee to come to the Center to complete the WV Cares Application to initiate the background check process. Agency personnel who have no submitted their application and completed their fingerprints will not be place on the schedule to work. Administrator/designee will re-educate Human Resources Manager/designee on the WV Clearance for Access (WV Cares) and Employment Screen System as required by Centers for Medicare and Medicaid Services (CMS) with a post-test to validate understanding. Administrator/Designee with complete a review of New Hire/Agency personnel files on (MONTH) 17, (YEAR) to ensure an application and fingerprints have been initiated prior to new hire beginning work in the Center to ensure completion of the WV Cares with confirmed eligibility to work in the Center for 30 days. Trends identified will be reported by the Administrator/Designee monthly to the Quality Improvement Committee for any additional follow-up until the issue is resolved and randomly thereafter as determined by QIC. | 2020-09-01 |