Non-Compliance with Employee Identification Badge Requirements
Summary
The facility was found to be non-compliant with the regulation requiring employees to wear identification badges. During an observation and interview with the facility's maintenance assistant, it was noted that Employee E2 did not have an identification badge while on a tour of the facility. This observation took place on January 31, 2025, at 10:00 a.m. Additionally, a licensed nurse, Employee E1, was observed on the third-floor unit without an identification badge on the same day at 1:00 p.m. The facility's policy, revised on January 3, 2022, mandates that employees must wear photo identification tags containing a recent photograph, the employee's first name, title, and the name of the health care facility or employment agency. The absence of identification badges for these employees indicates a failure to adhere to the established standards for identification badges as per Act 110.
Plan Of Correction
1) E1 and E2 will be provided with ID badges. 2) Current employees will be audited to ensure they have an ID badge available to them. 3) Current employees will be re-educated on ensuring they are wearing their name badge at all times and how to obtain one if they don't have one. 4) HR director will do random audits weekly X4 and monthly X2 to ensure staff are wearing their ID badge as necessary. Results will be reviewed monthly in QAPI and determined if further auditing is necessary.
Penalty
Six employees, including a COTA, LPNs, and an RN, were observed without the required photo identification badges, which should include a photo, first name, title, and facility name. The Director of Nursing confirmed the facility's failure to provide these badges.
Failure to Display Required Identification Badges
Penalty
Summary
The facility failed to ensure that six employees displayed identification badges as required by the Photo Identification Tag Regulation. The regulation mandates that staff must wear a photo identification tag that includes a recent photograph, the employee's first name, the employee's title, and the name of the health care facility or employment agency. During observations and interviews conducted on March 10, 2025, it was found that employees E9, E16, E17, E18, E19, and E20 did not display the required identification badges. Employee E16, a Certified Occupational Therapist Assistant, and Employee E17, a Licensed Practical Nurse, both stated that they had not been provided with photo identification badges since starting their employment. Similarly, Employees E9, E18, E19, and E20 were observed without the necessary identification tags. The Director of Nursing confirmed the facility's failure to ensure that these employees wore photo identification tags with the required information.
Plan Of Correction
A name badge sign-up sheet was created to identify any staff member in need of a badge. The Human Resources designee completed an audit of current staff to ensure they have proper identification badges. ID badges have been ordered for any staff member in need. To prevent this from recurring, the Director of Nursing/designee re-educated Human Resources on the requirements of photo identification tags. Human Resources Designee will provide new employees with name badges upon hire. To monitor and maintain ongoing compliance, the Nursing Home Administrator/designee will randomly audit 4 staff on duty for name badges weekly x4, then monthly x2 to ensure employee has appropriate photo identification tag on. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
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