**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement abuse, neglect policies that addresses screening of a potential employee's license which resulted in an employee being allowed to work as a nurse with no license or education check for 1 (Staff Member G) of 24 staff . The facility failed to screen Staff Member G to ensure she was licensed to practice as a GVN through the TX-BON. As a result Staff Member G was allowed to provide care and services to residents outside of her scope that included administration of medications that included PICC line normal saline flushes, short, long, sliding scale insulins and narcotics, wound care for stage III (3) wounds, monitoring of dialysis ports, PICC lines, and catheters with no direct supervision and providing supervision to certified nurse aides and medication aides. Staff Member G worked at the facility in the capacity of a GVN without legal authority from 11/24/24 to 01/31/24. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. While the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for minimum harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure could place residents at risk of receiving inappropriate care, abuse or neglect. Findings included: Record review of facility policy labeled Abuse Investigations undated revealed: Preventing Abuse. Employee Background Checks. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff .Screening. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum. Protocols for conducting employment background checks . Background Criminal Investigations and Pre-employment Testing. Screenings. State and Federal law mandates that certain persons with convicted of certain crimes or otherwise legally excluded, may not be employed in most facilities and agencies providing care to the aged and disabled . The organization also cheeks the C.N.A. Registry, The Misconduct Registry, the EPLS (Excluded Parties List System) and the OIC (Dept. of Health & Human Services Office of Inspector General List of Excluded Individuals/Entities per chapter 93 of the Texas Admin.Code and Chapter 253 of the Texas Health and Safety Code) on all individuals . For certain positions, this organization may conduct an extensive investigation of applicant's background, with written approval, including but not limited to: personal employment references/records, . and educational records, as well as other background information as deemed appropriate. In an interview on 01/31/24 10:12 PM with the DON and Staff Member G, Staff Member G said she had attended nursing school in New York state. She said she was waiting on her transcript from her school to get a date to test in TX. She said she assumed she was good to work in TX because she was hired as a GVN. The DON said it would be the ADON and HR responsibility to check for current valid licensure. In an interview on 2/1/24 at 12:18 PM the DON said that STAFF MEMBER G would be responsible for the number of residents in the high twenties each shift. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. Record review of Staff Member G's personnel file revealed: Application dated 11/21/23-Position applied for GVN/LVN with previous experience as an LPN from 062023 to current (11/21/23) reason for leaving-relocating. Another previous experience was as a Student Nurse from 06/2021 to 06/23. Interview Questions by ADON A, dated 11/21/23- What experience do you have working in (nursing, laundry, housekeeping, food service, etc)? I previously worked w/pts in their homes assisting with ADL's, nursing school clinicals and as an LPN in a pediatric office . Additional notes and comments. I am eligible to work with a graduate nurse permit until I pass my NCLEX in Texas. Employment Acknowledgement dated 11/21/23- Signed by both Staff Member G and ADON A revealed a position of GVN and a date of hire 11/24/23. Position Description Job Title: Licensed Vocational Nurse last revised 11/2019-Signed by Staff Member G 11/27/23. TXBON NCLEX PN Application dated 11/03/23 revealed: Applicants must submit the following items for their file to be considered complete & ready for an ATT review: 1.NCLEX-PN Application and $75 fee. 2.Fingerprint submission for a criminal background check (CBC) completed through IdentoGo. You will receive an email from IdentoGo with instructions on how to complete your fingerprints. The email will not be sent until we've received your NCLEX Application. Most applicants won't need to complete this step if they previously submitted fingerprints as a student or on a previous application. You will receive an email from IdentoGo if Board staff confirms that you are required to re- fingerprint 3.Completion of the Nursing Jurisprudence Exam (NJE). You do not need to retake the NJE if you completed it during a previous licensure application. 4. Registration with Pearson [NAME]. The name on your ID must match exactly the name you provided person view when you registered. If your name doesn't match, you will not be allowed to test and you will be required to reapply to receive a new ATT. 5. Affidavit of graduation parentheses (AOG) parentheses submitted by your program Dean [NAME] slash director after graduation. Texas graduates: your program dean\/director will submit the AOG electronically through the AOG portal. Your information will only appear in the AOG portal if you provided the correct school code and graduation date on your influx application. Out of state graduates: your program Dean/director will need to complete and submit the paper affidavit of graduation. *Keep in mind that additional application requirements may be added at any time during the review process An incomplete application and/or failure to complete pending items could delay the issuance of an ATT, Graduate Vocational Nurse (GVN) permit, if eligible, and permanent licensure . 10. I certify by entering my name below, I am the person applying for licensure with Texas Board of Nursing and meet the qualifications required by Texas law and regulations. Further, I certify the information provided in this application has been personally provided and reviewed by me and that the statements, documentation, and information submitted via the online application through an Internet interface are true, accurate, and complete, in every respect. I have not used a false or fictitious name in said application. I read and understand the questions and statements in the application and will abide by all current state and federal laws and regulations affecting nursing licensure. I understand that providing false or misleading information, as well as omitting pertinent or material information in connection with this application, is grounds for negative licensure consequences, which may include licensure denial or revocation and may subject me to civil or criminal penalties. I consent to the release of confidential information to the Texas Board of Nursing and further au1horizc the Board to use and lo release said information as needed for the evaluation and disposition of my application. Further, I understand that If l have any questions regarding this affidavit, I may contact an attorney. Signed 0926/23 . Payment date 11/03/23 . NOTE: This document is a copy of the electronic license application for the person named above and does NOT constitute a verification of license or represent a copy of the individual's license. There was no verification of license to practice as a GVN from the TX BON in Staff Member G's personnel file. Record review of Daily Assignment Sheets from 11/01/23 to 02/15/24 revealed: Staff Member G worked on 11/24/23 2-10p shift with LVN F on the 400 halls. 11/27/23 2-10p with LVN [NAME] the 400 hall. 11/28/23 2p-10p with LVN J on the 400 hall. 11/29/23 2p-10p with LVN K on 400 hall. 11/30/23 2p-10p with no other nurse on 400 hall, 3 other nurses on the shift. Total of 4 days with another nurse after hire date of 11/24. Total of 1 day in November of 2023 with no other nurse on the hall with Staff Member G. 12/01/23 2p-10p with no other nurse on 400 hall. 12/04/23 2p-10p with no other nurse on 400 hall. 12/05/23 2p-10p with no other nurse on 400 hall. 12/06/23 2p-10p with no other nurse on 400 hall. 12/07/23 2p-10p with no other nurse on 400 hall. 12/11/23 2p-10p with no other nurse on 400 hall. 12/12/23 2p-10p with no other nurse on 400 hall. 12/18/23 2p-10p with no other nurse on 400 hall. 12/19/23 2p-10p with no other nurse on 400 hall. 12/20/23 2p-10p with no other nurse on 400 hall. 12/21/23 2p-10p with no other nurse on 400 hall. 12/22/23 2p-10p with no other nurse on 400 hall. 12/25/23 2p-10p with no other nurse on 400 hall. 12/26/23 2p-10p with no other nurse on 400 hall. 12/27/23 2p-10p with no other nurse on 400 hall. 12/28/23 2p-10p with no other nurse on 400 hall. 12/29/23 2p-10p with no other nurse on 400 hall. 17 days in December of 2023 with no supervision on hall 400. 01/01/2024 2p-10p with no other nurse on 400 hall. 01/02/24 2p-10p with no other nurse on 400 hall. 01/03/24 2p-10p with no other nurse on 400 hall. 01/04/24 2p-10p with no other nurse on 400 hall. 01/08/24 2p-10p with no other nurse on 400 hall. 01/09/24 2p-10p with no other nurse on 400 hall. 01/10/24 2p-10p with no other nurse on 400 hall. 01/11/24 2p-10p with no other nurse on 400 hall. 01/15/24 2p-10p with no other nurse on 400 hall. 01/16/24 2p-10p with no other nurse on 400 hall. 01/17/24 2p-10p with no other nurse on 400 hall. 01/18/24 2p-10p with LVN K on 400 hall. 01/22/24 2p-10p with no other nurse on 400 hall. 01/23/24 2p-10p with no other nurse on 400 hall. 01/24/24 2p-10p with no other nurse on 400 hall. 01/30/24 2p-10p with no other nurse on 400 hall. 16 days in January 2024 with 15 of those days with no supervision on hall 400. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. During an interview on 02/15/24 at 4:55PM, the ADM said he did not have a license screening policy, but he would try to look for something. During a telephone interview on 02/16/24 at 10:01 AM with New York (NY) state Nursing college, the Registrar verified that Staff Member G completed the Vocational/Practical Nursing program and graduated 06/15/2023. The Registrar said that Staff Member G's name was not released to the state of NY [NAME] due to nonpayment. She said a person's name was sent to NY [NAME] after they had graduated the nursing program and paid their balance due to the school so they could register to take the NCLEX. The Registrar said record still showed a balance due. She said their system updated daily so if Staff Member G paid her balance due that day, then she could have her name released and be eligible to sit for the NCLEX. During a telephone interview on 02/16/24 at 02:20 PM NY [NAME] said, Staff Member G would not be eligible to use the GPN status. Her completion of the practical nursing program had been submitted to the NY [NAME] however Staff Member G never went further and tested. He said in the state of New York a person could practice as a GPN from the date of graduation to 90 days later without the need to apply. However, he said it was only valid for 90 days which would have run out on 09/15/23 for graduate nursing status. He said that would be the time to test and pass the NCLEX, but if a person had not passed the test or scheduled to test within those 90 days, then they would have to stop practicing as a GPN after the 90 days. NY [NAME] said Staff Member G did not have any status with New York. He said she never applied in any way in NY state. During a telephone interview on 02/16/24 at 03:13 PM with TXBON, she told me Staff Member G had only paid for her NCLEX and applied to take the exam. She said Staff Member G had not submitted an affidavit from her nursing school, graduation confirmation, or scheduled and submitted her fingerprints. She said Staff Member G had to schedule for her fingerprints with a specific approved TX BON approved company as it was federal, and it would tie in with her background check. TX BON said it would only be after Staff Member G had provided all the previous mentioned items, that Staff Member G could get an ATT. It would only be after any person was given the ATT in the state of Texas, that they could then apply with the TX BON for a nursing permit. Only after all these steps were completed, could any person legally represent themselves as a GVN in the state of TX. TX BON said that Staff Member G education had been verified and she was educated, but nothing further. TXBON said Staff Member G had not completed all the steps required in TX to legally practice as a GVN. During an interview on 02/16/24 at 05:31PM PM with HR, she said it was her responsibility to obtain a completed application from an individual. She said it was her responsibility screen the application and direct the person and their application to the proper department. She said if it was a nurse, being a GVN, GN, LVN or RN and a nurse aide or medication aide, then she sent the person and their application to the ADON A for interview. After ADON A had interview and would want to go with that person then she would discuss the pay, verify their license, do the reference checks, and background checks. She said that as a GVN or GN a nurse would not show up under the TXBON because there is not a section for GVN or GN status only LVN or RN status and because they were neither she would not be able to look on the TXBON. So, she said that she made the potential employee show them that they graduated from a nursing school and/or transcript that showed they completed a vocational nursing or registered nursing program at a college. HR said with the graduation she thought that automatically made them a GVN or GN. She said that Staff Member G had made her aware that she paid to test when she was hired, and that it was from NY and that the TXBON was just waiting for her transcripts to schedule a test for the NCLEX nursing exam. HR was aware that if Staff Member G did not pass the test, then she would not be allowed to work as a GVN any longer. HR said she spoke to Staff Member G sometime in the first part of January about her test and Staff Member G told her that she was still waiting to hear back from TXBON and had not heard anything. HR said that she just did not like hiring anyone that was not already licensed as a nurse in the state of Texas or in a compact state with Texas. She said it was just too hard to verify that information and she did not realize that there were several steps beyond graduating from nursing school to use the title of GVN or GN. This was determined to be an Immediate Jeopardy on 02/16/24. The ADM was provided the Immediate Jeopardy template on 02/16/24 at 8:55PM and a Plan of removal was requested. The following Plan of Removal submitted by the facility and accepted on 02/18/24 at 2:00PM Facility has no practicing GVN in the building. Staff member G was terminated on 1/31/2024. Facility will not hire GVN's or GN's as of 1/31/2024. DON audited all residents that could have suffered from Staff Member G providing nursing services 2/1/2024. No notable adverse effects were found during audit on 2/1/2024. DON/ designee will Audit residents using 24 nursing report starting 2/2/2024, that could have suffered from Staff Member G providing care, weekly-X4. CorpHR/Designee immediately in-serviced Administrator, HR, and Nursing Administration staff Including DON and ADON's on the facility's abuse and neglect policies starting 2/18/2024 11AM. Facility updated and implemented a written screening process on 2/17/2024, to include that any applicant with GVN/GN status will immediately stop the hiring process, and to ensure all professional staff are licensed, certified, or registered in accordance with applicable State laws to include Candidate applies in person at the facility. The hiring manager interviews the candidate. Candidate completes the background release forms and submits to HR at the conclusion of a successful interview. HR processes all required background and reference checks per company and state regulations. a. Texas Department of Public Safety b. Misconduct registry (EMR) c. Texas OIG d. Texas OIG exclusion e. C.N. A/ Med Aide Registry f. Texas BON Licensure Verification g. Sanctions Search h. SAM i. EVerify If a candidate has been prohibited from employment due to offenses listed under the Texas Health and Safety code or the Texas BON, HR will notify the candidate of this information and will not be employed by the facility. If a candidate has successfully completed the background checks an offer will be made and an invitation for new hire orientation will be scheduled. Corp.HR/Designee will be responsible for monitoring of the screening process starting 2/18/2024, WeeklyX4, monthlyX2, and quarterlyX3. Corp.HR/Designee will review new hire packets daily, or as needed with each new hire. All future new-hire licensed professional staff will have completed competencies prior to floor orientation. DON/designee will be responsible for competency training, with licensed professionals being able to provide return demonstration of skills. All current licensed professionals have been verified for current licensure as of 2/14/2024. Medical Director notified 2/16/2024 of IJ. IJ processes completed on 2/17/2024 will be brought to ADHOC QA meeting 2/18/2024 with Corp.HR/Designee and will continue with monthly QA X3 months, and quarterly X3 thereafter, to include Corp.HR/Designee. Monitoring of the facility's POR began on 02/18/24 at 2:00PM Record review of Staff Member G HR employee status effective date 1/31/24 revealed: Voluntary Termination. Rehire Eligability- Not Eligible for Rehire. Record review of Resident Roster for 400 Hall dated 02/01/24 revealed no adverse events for any resident. Record review of Resident Roster for 400 Hall dated 02/08/24 revealed no adverse events for any resident. Record review of Resident Roster for 400 Hall dated 02/15/24 revealed no adverse events for any resident. Record review of Inservice labeled Abuse/Neglect/Hiring GVN/GN screening process dated 02/18/24 by Corporate Nurse Consultant/HR designee 1Facility will conduct employment background checks, reference checks, criminal conviction investigations and licensing determination for all professional staff. 2. No GVN or GN's will be hired Any questions regarding licensing and or background checks will be referred to corporate HR. Brief evaluation of the participants responses to the inservice Question and Answer All hiring managers verbalized understanding of the hiring process to include screening of all applicants. Inservice staff included via signature of attendance ADM, DON, ADON A, ADON B, HR, Record review Abuse Investigation Policy dated Preventing Abuse-Employee Background Checks. Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual Screening-Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern as a minimum. Inservice dated 2/16/24 Abuse/Neglect- by DON and ADON B Definition of Abuse Post test on abuse by all above mentioned staff on 2/17/24 as well as 3 agency staff. Record review of LVN/RN licensure verifications dated 02/14/24 revealed: 3 RNs licensed to practice as a Nurse 16 LVN's all nurses at the facility were licensed to practice as a LVN or RN. Record review of facility policy labeled Personnel-Hiring and Employment - Background Screening Investigations undated revealed: Our facility conducts background screening checks reference checks and criminal conviction investigation checks on individuals making application for employment with our facility For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's' license. Record review of Employee Interview Questions undated revealed Question 1. 1. Do you have a current Texas nursing license? 2. If multi state, are you making Texas your permanent address? Record review of Employee Hiring Checklist undated revealed a section labeled Start Hiring Process that required initials and included https://txbn.boardof for the TXBON nursing license verification and nursing.org/licenselookup/?o=a3sKM1JioWd3avR7gp56JIFyka2AHSC7QzdAW9VmtM%3D to assist a [NAME] search for other state's nursing verifications. Nursing Proficiency Record review of QAPI meeting dated 02/18/24 revealed: Area: Hiring a Non licensed professional (GVN) Standard: All professional staff will be licensed, certified, or registered. The facility will not hire GVN or GN Observation: An out of state graduate nurse was hired without a proper permit from the state of Texas Implementation: 1. The Hiring Manager will conduct employment background check, reference checks, and criminal conviction checks on persons making application for employment within the facility. 2. Any licensed professional applying for a position that may involve direct contact with residents, his\ her licensing board will be contacted to determine if any sanctions have been assigned against the applicant's license, if his\ her license is valid in the state of Texas, and or if the out of state license is in the process of being reviewed by the Texas State board of nursing and application fee has been paid. During an interview on 02/18/24 at 4:00PM with HR, she said that the new system was that when someone filled out an application, they would give it to her and she only asked what position they were applying for, then would take the person and their application to the appropriate department managers. She said any floor nurse would be interviewed by the ADON's. She said they had a new interview questionnaire that the nurses had to go through that asked if the nurses were licensed or just GVN/GN. HR said if the person was a GVN or GN then the facility could not hire them. After the person had their interview with the department managers, then they were brought back to her to do the background checks and licensure verifications. A new item that was added as well was a new hiring checklist. It included what needed to be done with the initials to the side after completion. The checklist included the TXBON. If they are from out of State, the DON will have already been notified, but she will direct the person's verification to her again. HR said if she was ever in doubt about anything she was to call her Corporate HR manager for clarification. During an interview on 02/18/24 at 4:30PM with ADON A and ADON B, they both said that the facility began a new set of interview questions with the top question for nurses being if they were currently licensed in TX as a nurse and if the person said they were a GVN or GN, then they were supposed to stop the interview right there, because the facility no longer hired a GVN or GN. If they have a license to practice in another state then the interview also stops and that person will go to the DON for an interview, because there are times when there is only a certain amount of time they can work in TX. ADON B said that both the ADON's would do the competency skills check-off for any new LVN, and the DON would do the competency check for any new RN prior to the new employee's first day of work on the floor with the residents. They both said that they were not part of the monitoring of the new hire packet reviews. During an interview on 02/18/24 at 4:50PM with DON and ADM. They both said the facility no longer hired GVN's or GN's at the facility. They had to already have a license to practice as an LVN or RN in the state of TX. The DON said any person that was to be interviewed that had a license from a different state was directed to her because some are only granted a short window of time that they could practice in Texas and she would have to verify those dates as well as if they were legal to practice in Texas as some states did not offer a compact status and were only for each individual state. Both ADM and DON said they had never been a part of the verification of professional licenses in the past and always left it to HR. It had not been until survey team asked the question regarding Staff Member G's license that they realized it had never been checked. The DON said after it was brought to their attention, they terminated Staff Member G. ADM said they had a meeting earlier in the day and had been developing the new hiring checklist that included all the different websites that had to be checked to also include the TXBON. The DON said they revamped their employment interview questions as well to include the license status as the first question. She said that would save time in the beginning because the first question asked if a person was a GVN or GN and that would stop the interview. She said it would then be directed to the person that the facility did not hire GVN or GN, so they would need to wait until they got full LVN or RN license before they could come back and reapply. The ADM said the Corporate HR, himself, and DON would review any future hiring packets as they were completed to ensure everything had been covered. The DON said she took a resident roster for the 400 hall and reviewed through all their nurses' notes, lab orders, MAR's, TAR's, and the 24-hour report sheets during the time Staff Member G had been on duty and had not noted any adverse events during those times. She said she continued to monitor the residents weekly reviewing the 24-hr report sheets since Staff Member G was terminated. The ADM said he notified the Medical Director 02/16/24 after the IJ was presented to him. The DON said HR verified all the current nurses' licenses on 2/14/24. The ADM was informed the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure professional staff was licensed in accordance with applicable State laws for 1 (Staff Member G) of 24 personnel reviewed for licensed nursing. The facility failed to verify if Staff Member G was licensed to practice as a GVN through the TX-BON. As a result, Staff Member G was allowed to provide care/services/treatment to residents including PICC line normal saline flushes, short, long and sliding scale insulins, narcotics administration, stage 3 wound care, monitoring of dialysis ports and catheters for 26 of 92 residents on 400 hall. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. While the Immediate Jeopardy was lowered on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated with a severity level of no actual harm with a potential for minimum harm due to the facilities need to evaluate the effectiveness of the corrective actions. These failures could place residents at risk of being provided care by staff who are not qualified per state law. Findings included: In an interview on 01/31/24 at 10:12 PM with DON and Staff Member G, Staff Member G said she had attended nursing school in New York state. She said she was waiting on her transcript from her school to get a date to test in TX. She said she assumed she was good to work in TX because she was hired as a GVN. the DON said it would be the ADON and HR responsibility to check for current valid licensure. In an interview on 2/1/24 at 12:18 PM the DON said that STAFF MEMBER G would be responsible for the number of residents in the high twenties each shift. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. Record review of Staff Member G's personnel file on 02/15/24 revealed: Application dated 11/21/23-Position applied for GVN/LVN with previous experience as an LPN from 062023 to current (11/21/23) reason for leaving-relocating. Another previous experience was as a Student Nurse from 06/2021 to 06/23. Interview Questions by ADON A, dated 11/21/23- What experience do you have working in (nursing, laundry, housekeeping, food service, etc)? I previously worked w/pts in their homes assisting with ADL's, nursing school clinicals and as an LPN in a pediatric office . Additional notes and comments. I am eligible to work with a graduate nurse permit until I pass my NCLEX in Texas. Employment Acknowledgement dated 11/21/23- Signed by both Staff Member G and ADON A revealed a position of GVN and a date of hire 11/24/23. Position Description Job Title: Licensed Vocational Nurse last revised 11/2019-Signed by Staff Member G 11/27/23. TXBON NCLEX PN Application dated 11/03/23 revealed: Applicants must submit the following items for their file to be considered complete & ready for an ATT review: 1 .5. Affidavit of graduation parentheses (AOG) parentheses submitted by your program Dean [NAME] slash director after graduation. Texas graduates: your program dean\/director will submit the AOG electronically through the AOG portal. Your information will only appear in the AOG portal if you provided the correct school code and graduation date on your influx application. Out of state graduates: your program Dean/director will need to complete and submit the paper affidavit of graduation. *Keep in mind that additional application requirements may be added at any time during the review process An incomplete application and/or failure to complete pending items could delay the issuance of an ATT, Graduate Vocational Nurse (GVN) permit, if eligible, and permanent licensure . 10. I certify by entering my name below, I am the person applying for licensure with Texas Board of Nursing and meet the qualifications required by Texas law and regulations. Further, I certify the information provided in this application has been personally provided and reviewed by me and that the statements, documentation, and information submitted via the online application through an Internet interface are true, accurate, and complete, in every respect. I have not used a false or fictitious name in said application. I read and understand the questions and statements in the application and will abide by all current state and federal laws and regulations affecting nursing licensure. I understand that providing false or misleading information, as well as omitting pertinent or material information in connection with this application, is grounds for negative licensure consequences, which may include licensure denial or revocation and may subject me to civil or criminal penalties. I consent to the release of confidential information to the Texas Board of Nursing and further au1horizc the Board to use and lo release said information as needed for the evaluation and disposition of my application. Further, I understand that If l have any questions regarding this affidavit, I may contact an attorney. Signed 0926/23 . Payment date 11/03/23 . NOTE: This document is a copy of the electronic license application for the person named above and does NOT constitute a verification of license or represent a copy of the individual's license. There was no verification of license to practice as a GVN from the TX BON in Staff Member G's personnel file. Record review of Daily Assignment Sheets from 11/01/23 to 02/15/24 revealed: Staff Member G worked on 11/24/23 2-10p shift with LVN F on the 400 halls. 11/27/23 2-10p with LVN [NAME] the 400 hall. 11/28/23 2p-10p with LVN J on the 400 hall. 11/29/23 2p-10p with LVN K on 400 hall. 11/30/23 2p-10p on 400 hall, 12/01/23 2p-10p with no other nurse on 400 hall. 12/04/23 2p-10p with no other nurse on 400 hall. 12/05/23 2p-10p with no other nurse on 400 hall. 12/06/23 2p-10p with no other nurse on 400 hall. 12/07/23 2p-10p with no other nurse on 400 hall. 12/11/23 2p-10p with no other nurse on 400 hall. 12/12/23 2p-10p with no other nurse on 400 hall. 12/18/23 2p-10p with no other nurse on 400 hall. 12/19/23 2p-10p with no other nurse on 400 hall. 12/20/23 2p-10p with no other nurse on 400 hall. 12/21/23 2p-10p with no other nurse on 400 hall. 12/22/23 2p-10p with no other nurse on 400 hall. 12/25/23 2p-10p with no other nurse on 400 hall. 12/26/23 2p-10p with no other nurse on 400 hall. 12/27/23 2p-10p with no other nurse on 400 hall. 12/28/23 2p-10p with no other nurse on 400 hall. 12/29/23 2p-10p with no other nurse on 400 hall. 17 days in December of 2023 with no supervision on hall 400. 01/01/2024 2p-10p with no other nurse on 400 hall. 01/02/24 2p-10p with no other nurse on 400 hall. 01/03/24 2p-10p with no other nurse on 400 hall. 01/04/24 2p-10p with no other nurse on 400 hall. 01/08/24 2p-10p with no other nurse on 400 hall. 01/09/24 2p-10p with no other nurse on 400 hall. 01/10/24 2p-10p with no other nurse on 400 hall. 01/11/24 2p-10p with no other nurse on 400 hall. 01/15/24 2p-10p with no other nurse on 400 hall. 01/16/24 2p-10p with no other nurse on 400 hall. 01/17/24 2p-10p with no other nurse on 400 hall. 01/18/24 2p-10p with LVN K on 400 hall. 01/22/24 2p-10p with no other nurse on 400 hall. 01/23/24 2p-10p with no other nurse on 400 hall. 01/24/24 2p-10p with no other nurse on 400 hall. 01/30/24 2p-10p with no other nurse on 400 hall. Record review of Resident Roster dated 01/29/24 revealed 26 residents on 400 hall. During an interview on 02/15/24 at 4:55PM, the ADM said he did not have a license screening policy, but he would try to look for something. During a telephone interview on 02/16/24 at 10:01 AM with New York (NY) state Nursing college, the Registrar verified that Staff Member G completed the Vocational/Practical Nursing program and graduated 06/15/2023. The Registrar said that Staff Member G's name was not released to the state of NY [NAME] due to nonpayment. She said a person's name was sent to NY [NAME] after they had graduated the nursing program and paid their balance due to the school so they could register to take the NCLEX. The Registrar said record still showed a balance due. She said their system updated daily so if Staff Member G paid her balance due that day, then she could have her name released and be eligible to sit for the NCLEX. During a telephone interview on 02/16/24 at 02:20 PM with NY [NAME], said, Staff Member G would not be eligible to use the GPN status. Her completion of the practical nursing program had been submitted to the NY [NAME] however Staff Member G never went further and tested. He said in the state of New York a person could practice as a GPN from the date of graduation to 90 days later without the need to apply. However, he said it was only valid for 90 days which would have run out on 09/15/23 for graduate nursing status. He said that would be the time to test and pass the NCLEX, but if a person had not passed the test or scheduled to test within those 90 days, then they would have to stop practicing as a GPN after the 90 days. NY [NAME] said Staff Member G did not have any status with New York. He said she never applied in any way in NY state. During a telephone interview on 02/16/24 at 03:13 PM with TXBON, she told me Staff Member G had only paid for her NCLEX and applied to take the exam. She said Staff Member G had not submitted an affidavit from her nursing school, graduation confirmation, or scheduled and submitted her fingerprints. She said Staff Member G had to schedule for her fingerprints with a specific approved TX BON approved company as it was federal, and it would tie in with her background check. TX BON said it would only be after Staff Member G had provided all the previous mentioned items, that Staff Member G could get an ATT. It would only be after any person was given the ATT in the state of Texas, that they could then apply with the TX BON for a nursing permit. Only after all these steps were completed, could any person legally represent themselves as a GVN in the state of TX. TX BON said that Staff Member G education had been verified and she was educated, but nothing further. TXBON said Staff Member G had not completed all the steps required in TX to legally practice as a GVN. During an interview on 02/16/24 at 05:31PM PM with HR, she said it was her responsibility to obtain a completed application from an individual. She said it was her responsibility screen the application and direct the person and their application to the proper department. She said if it was a nurse, being a GVN, GN, LVN or RN and a nurse aide or medication aide, then she sent the person and their application to the ADON A for interview. After ADON A had interview and would want to go with that person then she would discuss the pay, verify their license, do the reference checks, and background checks. She said that as a GVN or GN a nurse would not show up under the TXBON because there was not a section for GVN or GN status only LVN or RN status and because they were neither she would not be able to look on the TXBON. So, she said that she made the potential employee show them that they graduated from a nursing school and/or transcript that showed they completed a vocational nursing or registered nursing program at a college. HR said with the graduation she thought that automatically made them a GVN or GN. She said that Staff Member G had made her aware that she paid to test when she was hired, and that it was from NY and that the TXBON was just waiting for her transcripts to schedule a test for the NCLEX nursing exam. HR was aware that if Staff Member G did not pass the test, then she would not be allowed to work as a GVN any longer. HR said she spoke to Staff Member G sometime in the first part of January about her test and Staff Member G told her that she was still waiting to hear back from TXBON and had not heard anything. HR said that she just did not like hiring anyone that was not already licensed as a nurse in the state of Texas or in a compact state with Texas. She said it was just too hard to verify that information and she did not realize that there were several steps beyond graduating from nursing school to use the title of GVN or GN. Record review of TXBON regarding 15.15 Board's Jursidiction Over a Nurse's Practice in Any Role and Use of the Nursing Title accessed at Texas Board of Nursing - Practice - Nursing Practice on 02/28/24 revealed Use of any protected nursing title by an individual who is not licensed to practice either licensed vocational nursing or professional nursing in accordance with the licensing requirements in Texas, or who does not hold a valid compact license to practice nursing poses a potential threat to public safety related to this act of deception and misrepresentation to the public who may be seeking the services of a licensed nurse. In the opinion of the Board, the expressed or implied use of the title LVN, or RN, or any other title that implies nursing licensure requires compliance with the NPA and Board Rules. As stated in Rule 217.11(1)(A), the nurse is accountable to adhere to any state, local, or federal laws impacting the nurse's area of practice. This was determined to be an Immediate Jeopardy on 02/16/24. The ADM was provided the Immediate Jeopardy template on 02/16/24 at 8:55PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility and accepted on 02/18/24 at 2:00PM. Facility has no practicing GVN in the building. Staff member G was terminated on 1/31/2024. Facility will not hire GVN's or GN's as of 1/31/2024. DON audited all residents that could have suffered from Staff Member G providing nursing services 2/1/2024. No notable adverse effects were found during audit on 2/1/2024. DON/ designee will Audit residents using 24 nursing report starting 2/2/2024, that could have suffered from Staff Member G providing care, weekly-X4. Facility updated and implemented a written screening process on 2/17/2024, to include that any applicant with GVN/GN status will immediately stop the hiring process, and to ensure all professional staff are licensed, certified, or registered in accordance with applicable State laws to include: Candidate applies in person at the facility. The hiring manager interviews the candidate. Candidate completes the background release forms and submits to HR at the conclusion of a successful interview. HR processes all required background and reference checks per company and state regulations. a. Texas Department of Public Safety b. Misconduct registry (EMR) c. Texas OIG d. Texas OIG exclusion e. C.N. A/ Med Aide Registry f. Texas BON Licensure Verification g. Sanctions Search h. SAM i. EVerify h If a candidate has successfully completed the background checks an offer will be made and an invitation for new hire orientation will be scheduled. Corp./Designee in-serviced Admin, HR, DON, and ADON's on updated/revised screening process 2/18/2024, staff verbalized understanding. Corp.HR/Designee will be responsible for monitoring of the screening process starting 2/18/2024, WeeklyX4, monthlyX2, and quarterlyX3. Corp.HR/Designee will review new hire packets daily, or as needed with each new hire. All future new-hire licensed professional staff will have completed competencies prior to floor orientation. DON/designee will be responsible for competency training, with licensed professionals being able to provide return demonstration of skills. All current licensed professionals have been verified for current licensure as of 2/14/2024. Medical Director notified 2/16/2024 of IJ. IJ processes completed on 2/17/2024 will be brought to ADHOC QA meeting 2/18/2024with Corp.HR/Designee and will continue with monthly QA X3 months, and quarterly X3 thereafter, to include Corp.HR/Designee. Monitoring of the facility's POR began on 02/18/24 at 2:00PM Record review of Staff Member G HR employee status effective date 1/31/24- Voluntary Termination. Rehire Eligibility- Not Eligible for Rehire. Record review of Inservice labeled Abuse/Neglect/Hiring GVN/GN screening process dated 02/18/24 by Corporate Nurse Consultant/HR designee 1Facility will conduct employment background checks, reference checks, criminal conviction investigations and licensing determination for all professional staff. 2. No GVN or GN's will be hired Any questions regarding licensing and or background checks will be referred to corporate HR. Brief evaluation of the participants responses to the inservice Question and Answer All hiring managers verbalized understanding of the hiring process to include screening of all applicants. Inservice staff included via signature of attendance ADM, DON, ADON A, ADON B, HR, Record review of LVN/RN licensure verifications dated 02/14/24 revealed 3 RNs licensed to practice as a Nurse 16 LVN's all nurses at the facility were licensed to practice as a LVN or RN. Record review of facility policy labeled Personnel-Hiring and Employment - Background Screening Investigations undated revealed: Our facility conducts background screening checks reference checks and criminal conviction investigation checks on individuals making application for employment with our facility For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicants' license. Record review of Employee Interview Questions undated revealed Question 1. 1. Do you have a current Texas nursing license? 2. If multi state, are you making Texas your permanent address? Record review of Employee Hiring Checklist undated revealed a section labeled Start Hiring Process that required initials and included https://txbn.boardof for the TXBON nursing license verification and nursing.org/licenselookup/?o=a3sKM1JioWd3avR7gp56JIFyka2AHSC7QzdAW9VmtM%3D to assist a [NAME] search for other state's nursing verifications. Nursing Proficiency Record review of QAPI meeting dated 02/18/24 revealed: Area: Hiring a Non licensed professional (GVN) Standard: All professional staff will be licensed, certified, or registered. The facility will not hire GVN or GN Observation: An out of state graduate nurse was hired without a proper permit from the state of Texas Implementation: 3. The Hiring Manager will conduct employment background check, reference checks, and criminal conviction checks on persons making application for employment within the facility. 4. Any licensed professional applying for a position that may involve direct contact with residents, his\ her licensing board will be contacted to determine if any sanctions have been assigned against the applicant's license, if his\ her license is valid in the state of Texas, and or if the out of state license is in the process of being reviewed by the Texas State board of nursing and application fee has been paid. During an interview on 02/18/24 at 4:00PM with HR, she said that the new system was that someone filled out an application and would give to her and she only asked what position they were applying for, then would take the person and their application to the appropriate department managers. She said any floor nurse would be interviewed by the ADON's. She said they had a new interview questionnaire that the nurses had to go through that asked if the nurses were licensed or just GVN/GN. HR said if the person was a GVN or GN then the facility could not hire them. After the person had their interview with the department managers, then they were brought back to her to do the background checks and licensure verifications. A new item that was added as well was a new hiring checklist. It included what needed to be done with the initials to the side after completion. The checklist included the TXBON. If they are from out of State, DON will have already been notified, but she will direct the person's verification to her again. HR said if she was ever in doubt about anything she was to call her Corporate HR manager for clarification. During an interview on 02/18/24 at 4:30PM with ADON A and ADON B, they both said that the facility began a new set of interview questions with the top question for nurses being if they were currently licensed in TX as a nurse and if the person said they were a GVN or GN, then they were supposed to stop the interview right there, because the facility no longer hired a GVN or GN. If they have a license to practice in another state then the interview also stops and that person will go to the DON for an interview, because there are times when there is only a certain amount of time they can work in TX. ADON B said that both the ADON's would do the competency skills check-off for any new LVN, and the DON would do the competency check for any new RN prior to the new employee's first day of work on the floor with the residents. They both said that they were not part of the monitoring of the new hire packet reviews. During an interview on 02/18/24 at 4:50PM with DON and ADM. They both said the facility no longer hired GVN's or GN's at the facility. They had to already have a license to practice as an LVN or RN in the state of TX. DON said any person that was to be interviewed that had a license from a different state was directed to her because some are only granted a short window of time that they could practice in Texas and she would have to verify those dates as well as if they were legal to practice in Texas as some states did not offer a compact status and were only for each individual state. Both ADM and DON said they had never been a part of the verification of professional licenses in the past and always left it to HR. It had not been until survey team asked the question regarding Staff Member G's license that they realized it had never been checked. DON said after it was brought to their attention, they terminated Staff Member G. ADM said they had a meeting earlier in the day and had been developing the new hiring checklist that included all the different websites that had to be checked to also include the TXBON. DON said they revamped their employment interview questions as well to include the license status as the first question. She said that would save time in the beginning because the first question asked if a person was a GVN or GN and that would stop the interview. She said it would then be directed to the person that the facility did not hire GVN or GN, so they would need to wait until they got full LVN or RN license before they could come back and reapply. ADM said the Corporate HR, himself, and DON would review any further hiring packets as they were completed to ensure everything had been covered. DON said she took a resident roster for the 400 hall and reviewed through all their nurses' notes, lab orders, MAR's, TAR's, and the 24-hour report sheets during the time Staff Member G had been on duty and had not noted any adverse events during those times. She said she continued to monitor the residents weekly reviewing the 24-hr report sheets since Staff Member G was terminated. ADM said he notified the Medical Director 02/16/24 after the IJ was presented to him. DON said HR verified all the current nurses' licenses on 2/14/24. The ADM was informed the Immediate Jeopardy was removed on 02/18/24 at 5:30PM, the facility remained out of compliance at a scope of isolated with a severity level of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.