Livingston Hills Nursing & Rehabilitation Center, LLC

Based on record review and staff interviews during a complaint investigation (Case # NY00105856), it was determined that the facility did not have effective policies and procedures in place to screen employees for a history of abuse, neglect or mistreatment of residents, or to verify that employees had current licenses and/or registrations to perform their jobs. Specifically, the facility did not ensure that three licensed practical nurses (LPN's # 1, 2 and 3) who were currently employed at the facility, had current and unrestricted licenses to practice nursing; and did not ensure that three of three certified nursing assistants (CNA's # 1, 2 and 3) who were employed at the facility, had current certifications to work as CNA's; and the facility did not have documentation to show that a CNA (CNA # 4), who was allowed to work prior to the return of the CNA's criminal history record check (CHRC), was supervised during her working hours. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by the following:

On 9/9/11, a review of the personnel record for a Licensed Practical Nurse (LPN #1) working at the facility on that day, revealed there was no evidence that the facility had verified that the LPN had a current license to practice as a nurse in New York State. The copy of the most recent license in LPN #1's personnel record showed that the LPN's license expired in July 2010. A review of employment records from August 1, 2011 to September 9, 2011 revealed that LPN # 1 had worked a total of 29 days

On 9/9/11, a review of the personnel record for a Licensed Practical Nurse (LPN #2) working on that day, revealed there was no evidence that the facility had verified that the LPN had a current license to practice as a nurse in New York State. The copy of the most recent license in LPN #2's personnel record showed that the LPN's license expired on 5/31/09. A review of employment records from August 1, 2011 to September 9, 2011 revealed that LPN # 2 had worked a total of 36 days.

On 9/9/11 a review of the personnel record for a Licensed Practical Nurse (LPN #3) working on that day, revealed there was no evidence that the facility had verified that the LPN had a current license to practice as a nurse in New York State. The copy of the most recent license in LPN #3's personnel record showed that the LPN's license expired on 10/31/10. A review of employment records from August 1, 2011 to September 9, 2011 revealed that LPN # 2 had worked a total of 34 days.

On 9/9/11 a review of the personnel records for CNA's # 1, 2 and 3, who were all currently working at the facility, revealed there was no evidence that the facility had verified that the CNA's had current certifications to work as CNA's in New York State. A review of information provided by the New York State Nurse Aide Registry on 9/8/11, revealed that CNA # 1's certification had expired on 4/30/09; CNA # 2's certification had expired on 8/31/11 and CNA # 3's certification had expired on 6/30/11.

On 9/9/11, a review of the personnel folder for CNA # 4 , who was currently employed by the facility and had been working since 8/15/11, revealed the facility had not yet received a return letter from the NYS DOH advising the facility on the CNA's eligibility for employment based on the CHRC. The DON was unable to provided documentation to verify that the CNA had been supervised during working hours.

During an interview on 9/9/11 at approximately 1:30pm, the Facility Administrator's, Administrative Assistant (AA) stated that she had sent the form to the DOH requesting a criminal history record check (CHRC) on CNA # 4 on or about 8/15/11. The AA stated that as of that date, 9/9/11, she had not yet received a response. In a phone inquiry on 9/26/11 at approximately 3:00 pm the AA stated that on 9/12/11 the response letter had come from the NYS DOH indicating their intent to deny eligibility for employment based on the CNA's CHRC and they would offer the employee the opportunity to explain in writing why employment should not be denied.

During an interview on 9/9/11 at approximately 1:30pm, the facility Director of Nursing (DON) was asked if she could provide documentation that LPN's # 1, 2 and 3 had a current New York State license to practice nursing and if CNA's # 1, 2 and 3 had current CNA certifications. The DON stated that she could not provide that documentation. She added that sometime after she became the facility DON she had asked someone on the staff if certification and licensing was being verified for all employees. She stated that she was told there was a system in place to verify that nursing licenses and CNA certifications were being checked. The DON could not recall who on the staff had assured her that there was an effective system in place. When asked for documentation to show that CNA # 4, who was working prior to a reply from the NYS DOH, was being supervised while working, the DON stated she could not provide documentation and did not know why is was not available.

10 NYCRR 415.11(c)(3)