Failure to Ensure Health Assessments for New Employees
Summary
The facility failed to comply with the regulation requiring a health care practitioner to determine that newly hired employees are free from communicable diseases. This deficiency was identified through a review of facility policy, personnel records, and staff interviews. Specifically, the personnel records of three employees—Housekeeping Staff Employee E1, Physical Therapist Employee E3, and Nurse Aide Employee E4—lacked documented evidence of such assessments prior to their employment. The facility's policy mandates that an employee's vaccination status, tuberculosis screening, and recent history of communicable diseases be assessed before or upon duty assignment. The personnel records revealed that Housekeeping Staff Employee E1 was hired in February 2025 and worked multiple days in February, March, and April without the required health assessment. Similarly, Physical Therapist Employee E3, hired in March 2025, and Nurse Aide Employee E4, hired in March 2025, also worked several days without documented health assessments. During an interview, Human Resources Employee E5 confirmed the facility's failure to ensure these assessments were conducted as required, leading to the identified deficiency.
Plan Of Correction
1. No residents experienced adverse effects. Housekeeping Staff Employee E1, Physical Therapist Employee E3, and Nurse Aide Employee E4 will have their physicals completed. 2. Physical assessment signed by a provider will be required during the pre-employment process to determine that staff are free from communicable diseases. 3. NHA to educate HR Director/designee on need for physical assessment signed by a provider during the pre-employment process to determine that staff are free from communicable diseases. 4. HR Director/designee to audit new employee orientation folders 1x/week for 4 weeks, then monthly x 2 months.
Penalty
Personnel files for a dietary aide and a nurse aide did not contain documentation from a licensed health care practitioner confirming that each employee was free from communicable diseases or conditions at the start of employment. The health forms were only signed by the employees, not by a qualified practitioner, as confirmed by HR staff.
A newly hired LPN began providing resident care without documentation from a healthcare practitioner confirming they were free from communicable diseases, as required by regulation. The administrator confirmed the absence of this documentation in the employee's file.
Missing Practitioner Verification of Employee Health Status
Penalty
Summary
The facility failed to ensure that personnel records for two employees, a dietary aide and a nurse aide, included documentation from a licensed health care practitioner verifying that each employee was free from communicable diseases or conditions as of their start date. Review of the personnel files showed that the required health forms were present but were only signed by the employees themselves, not by a physician, nurse practitioner, or physician's assistant. This omission was confirmed during an interview with a human resources staff member, who acknowledged that the necessary practitioner verification was missing from the files reviewed.
Plan Of Correction
Employe 1 and 2 had their physical forms reviewed and signed by health care practitioners. Human Resource Director will make review the last 10 new hires physical form to verify they were signed prior to starting employment clearing them form communicable diseases. Director of Nursing or Designee will Human Resources on required physical form signed prior to starting employment clearing them form communicable diseases. Human Resources or designee will audit the New hire employee files to assure all required signatures are completed. Audit results will be turned into Quality Assurance meeting monthly.
Lack of Communicable Disease Clearance for New LPN Hire
Penalty
Summary
The facility failed to ensure that an employee was assessed by a healthcare practitioner and determined to be free from communicable diseases or conditions prior to providing resident care. Specifically, a review of the personnel file for a Licensed Practical Nurse revealed that there was no documentation showing a healthcare practitioner had made this determination at or before the employee's hire date. During an interview, the Nursing Home Administrator confirmed that the required written determination was not present in the employee's file as mandated by regulation.
Plan Of Correction
Employee #6 received her physical. To identify like residents that have the potential to be affected. NHA/designee to audit new hire files for the last 14 days to ensure personnel files contain employee physical. To prevent this from recurring, Human Resources educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee to audit new personnel files weekly x4 then monthly x 2 to ensure personnel files contain employee physical. Results to QAPI for recommendations and follow-up.
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