Other·July 18, 2023

F839 Code of Federal Regulations, Title 42, Section §483.70(f) Staff qualifications (1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements. (2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws. California Code of Regulations, Title 22, Section 72327, Nursing Service – Director of Nursing Service (a)The director of nursing service shall be a registered nurse and shall be employed eight hours a day, on the day shift five days a week. On 6/29/2023 at 8:30 am., the California Department of Public Health conducted an unannounced recertification survey. As a result of the investigation, the Department determined the facility failed to ensure Director of Nursing 2 had an active and valid Registered Nurse (RN) license upon hire on 5/24/23 in accordance with the facility's job description, Policy and Procedure (P&P), and State law. As a result of these failures, the facility employed a DON without validating qualifications, knowledge, and skills to practice nursing safely and supervise all licensed nurses, which had the potential to affect the care and well-being of all patients residing at the facility. During an interview on 6/29/23 at 9:58 AM with DON 2, DON 2 stated the facility hired DON 2 on 5/24/23. During a concurrent interview and review of employee personnel files on 6/29/23 at 11:32 AM with the Director of Staff Development (DSD), the DSD stated she would provide DON 2's personnel file prior to leaving the facility on 6/29/23. During a review of DON 2's Employment Application, dated 5/22/23, the Employment Application indicated DON 2 had a professional license as a Registered Nurse (RN) in the State (California). The expiration date for DON 2's RN license on the Employment Application was left blank. During a review of DON 2's signed job description titled, "Director of Nursing Services," the signed job description indicated DON 2's date of hire was on 5/24/23. DON 2's signed job description indicated specific job requirements including but not limited to possessing a current and active license to practice as a RN in the State. During a review of the State RN license verification website (www.DCA.ca.gov), DON 2's State RN license was "delinquent," renewal fees had not been paid and the license expired on 4/30/23. The State RN license verification website indicated DON 2 was not permitted to practice as a RN until the license was renewed and in active status. During an interview on 6/29/23 at 3:38 PM with the Administrator (ADM) and DON 2, the ADM stated the DSD and the ADM were responsible for hiring personnel. DON 2 stated the DSD and DON 2 were aware DON 2's RN license was expired upon hire. DON 2 stated DON 2 attempted to renew the RN license but was unable to because DON 2 had to complete the required continuing education (educational activities which serve to maintain, develop, or increase professional knowledge and skills). DON 2 stated DON 2 submitted the renewal application for the RN license on 5/26/23 or 5/29/23 after completing the continuing education but did not have any documentation of the submission. The ADM stated the ADM knew DON 2 had an expired RN license at the beginning of the month (6/2023, specific date unknown). The ADM and DON 2 stated a qualification to be the facility's DON included a current and active RN license. The ADM stated it was important for DON 2 to have an active license because DON 2 managed all licensed nursing staff. During a review of the facility's P&P titled, "License Verification," dated 6/2023, the P&P indicated the "Human Resources Director, or designee, is responsible for maintain and ensuring the validity and current status of individual certification/licensure." During a concurrent interview and review of the facility's P&P tilted, "License Verification," on 6/30/23 at 12:30 PM with the ADM, the ADM stated the DSD was the designee responsible for verifying the staff's State licensure status. As a result of the investigation, the Department determined the facility failed to ensure Director of Nursing 2 had an active and valid RN license upon hire on 5/24/23 in accordance with the facility's job description, P&P, and State law. As a result of these failures, the facility employed a DON without validating qualifications, knowledge, and skills to practice nursing safely and supervise all licensed nurses, which had the potential to affect the care and well-being of all patients residing at the facility. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all the patients at the facility.