Based on a review of license verifications of Registered Nurses (RN) and staff interview, it was determined that the facility failed to make certain a RN was working with a valid license for one of 23 nurses (RN Employee E1).
A review of RN Employee E1's license verification revealed an expiration date of 10/31/17. RN Employee E1 worked in the building from 11/1/17, through 4/23/19, a total of 226 days with an expired license.
During an interview on 5/6/19, at 10:30 a.m., the Nursing Home Administrator confirmed that the facility failed to make certain RN licenses were not expired.
28 Pa. Code: 211.12.(e) Nursing services.
| ||Plan of Correction - To be completed: 05/14/2019|
1. We immediately suspended the Registered Nurse pending her receiving a valid license.
2. Using the approved online license verification system, we verified the licenses of every licensed professional employed by the facility up to and including the Nursing Home Administrator and Director of Nursing. All licenses were found to be in compliance.
3. The New Human Resources Director was educated on the license requirements for long-term care. The Human Resource Director will keep a running list of all licensed professionals in the building (newly hired employees will be added to this list during orientation and terminated employees will only be removed from the tracking spreadsheet once they are removed from the payroll system). This list will be reviewed at the beginning of the month for any employee due for license renewal in the next 60 days. Those employees will be notified by the Human Resource Director or designee that their license is due for renewal and that they will not be able to work after their renewal date until a valid license is verified in the online system. The suspended employee's hours have also been removed from the 2019 PBJ log.
4. The Nursing Home Administrator will audit this list monthly for the next three months with the Director of Human Resources for accuracy and to verify the systemic change is working. These audits will be taken to the Quality Assurance Performance Improvement Committee for review and any negative results will be discussed for any required follow-up.
5. Plan of correction date of compliance: Tuesday, May 14, 2019.