John H Stroger Jr Hospital

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 2 patients’ (Pt. #2 and Pt. #3) clinical records reviewed regarding treatment planning, the hospital failed to ensure that documentation regarding patients receipt of information and participation in treatment planning were documented. Findings include: 1. On 3/31/2025, the hospital’s policy titled, Rights and Responsibilities of the Individual” (10/2023) were reviewed and included, “Purpose... to define the patient rights... in relation to their healthcare... Procedure/Process... Attachment A... You have the right to... participate in your care plan in a way you understand. To receive information regarding medical diagnosis, procedures, treatment... “ 2. On 3/31/2025, the clinical record for Pt. #2 was reviewed. On 3/28/2025, Pt. #2 was admitted to the hospital with a diagnosis of hematuria (blood in urine). The providers/physicians’ progress notes on 3/29/2025, 3/30/2025 and 3/31/2025 did not include documentation that Pt. #2 received information and participated in the treatment planning. 3. On 3/31/2025, the clinical record for Pt. #3 was reviewed. On 3/28/2025, Pt. #3 was admitted with a diagnosis of black stool. The providers/physicians’ progress notes on 3/29/2025, 3/30/2025, and 3/31/2025 did not include documentation that Pt. #3 received information and participated in treatment planning. 4. On 3/31/2025 at approximately 10:45 AM, findings were discussed with MD #1 (Assistant Medical Director). MD #1 stated that to ensure that patients are informed of their care, the practice is to document in the progress notes that the care (plan) was discussed with the patient, and that patient’s questions or concerns were addressed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 4 patients’ (Pt. #4 and Pt. #5) clinical records reviewed for restraints, the hospital failed to ensure that the required hourly monitoring was documented. Findings include: 1. On 3/31/2025, the hospital’s policy titled, “Restraint and Seclusion” (4/2024) was reviewed and included, “Purpose: To ensure safety of our patients... Procedures/Process... C... 2. Medical Non-Violent/Non-Self Destructive Behavior. The patient’s behavior and physical needs are monitored and documented upon restraint placement and every 1 hour: a. Respiratory and Circulatory Status... b. Skin inspection. c. Range of motion... E. Restraint Discontinuation: 1. At the earliest possible time... restraint will be discontinued...” 2. On 3/31/2025, the clinical record for Pt. #4 was reviewed. On 3/15/2025, Pt. #4 was admitted to the hospital with a diagnosis of acute heart failure. On 3/21/2025 at 5:15 AM, a physician’s order was made to place Pt. #4 in two-point soft restraints for medical/non-violent behavior. There was no required hourly monitoring on 3/21/2025 at 9:00 AM and on 3/22/2025 at 8:00 PM, while Pt. #4 was in restraints. 3. On 3/31/2025, the clinical record for Pt. #5 was reviewed. On 3/1/2025, Pt. #5 was admitted to the hospital with a diagnosis of abdominal pain. On 3/3/2025 at 5:47 AM, a physician’s order was made to place Pt. #5 in two-point restraints for medical/non-violent behavior. There was no required hourly monitoring (or documentation when restraints were discontinued) on 3/3/2025 from 7:30 AM through 10:20 AM. 4. On 3/31/2025 between approximately 12:45 PM through 1:00 PM, findings were discussed with E #8 (Clinical Nurse Leader). E #8 validated that there was no documentation of the hourly monitoring while the patients were in restraints. E #8 stated that the hourly monitoring should have been documented.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 1 (Pt #1) pediatric, diabetic patient who presented to the Emergency Department (ED) for elevated blood sugar, the hospital failed to ensure that the patient received an appropriate medical screening examination, including monitoring and reassessment. Hospital A = John H Stroger Jr Hospital Hospital B = outside hospital where Pt #1 presented same day after discharge from Hospital A Findings include: 1. The hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)”, dated 3/22/24, was reviewed, and required, “ ...When an EMTALA obligation exists, an appropriate medical screening examination, within the capabilities of the hospital’s emergency department ...shall be performed to determine whether an emergency medical condition exists ...Once medical screening is complete and does not reveal an emergency medical condition ...the patient is treated and: 1. discharged when, within reasonable clinical confidence, the patient has reached the point where her/his continued care can be reasonably performed later as an inpatient or on an outpatient basis ...and the patient is given a plan for appropriate follow up care; or admitted as inpatient for continued care; or transferred for continued care ...” 2. The hospital’s “Pediatric EM Manual: Guideline for the Management of New Onset Diabetes and Diabetes Ketoacidosis” (undated), was reviewed, and included, “ ...For patient who are fully hydrated and well-appearing, the initial work up only needs to include: Glucose and Bicarbonate or glucose and a pH from a Venous Blood Gas (VBG) or an Arterial Blood Gas (ABG); Urine Ketones ...Definition: Diabetic ketoacidosis (DKA) consists of: Significant acidosis (arterial and venous pH <7.30); Hyperglycemia (serum glucose >200); Bicarbonate [less than or equal to] 15 mEq/L [milliequivalents/per liter] and significant ketosis (moderate to large urinary ketones) ...The endocrinologist on call is to be called with all lab test results.” 3. The clinical record for Pt #1 was reviewed on 11/12/2024. Pt #1 was a pediatric patient who presented to Hospital A’s Emergency Department (ED) on 7/26/2024 at 10:03 PM. Pt #1 was discharged home from Hospital A’s ED on 7/27/2024 at 1:25 AM. - The ED Triage Note (dated 7/26/2024 at 10:22 PM), documented by the Triage RN (E #6/registered nurse), included, “Primary Chief Complaint: Hyperglycemia [high blood sugar]. Pt with PMHx [past medical history] of T1DM [type I diabetes] with c/o [complaints of] hyperglycemia. [Pt #1’s parent/Z #2] states pts glucose was 495 [high blood sugar - normal range is 70-100] at [7:30 PM/approximately 3 hours prior to arrival] so [Z #2] gave 20 units of Humalog. [Z#2] reports [Pt #1] has been out of Lantus [long-acting insulin] for the past ‘few days’. Pt endorses feeling tired, denies any other complaints ...Acuity 3 [patient requires two or more different resources/ranges from 1-5, with 1 being the most critical].” - Pt #1’s ED Note (dated 7/26/2024 at 11:47 PM), documented by the ED Resident (MD #3), included, “ ...History of Present Illness: 15-year old male w/hx type 1 DM c/b [complicated by] hospitalization for DKA [diabetic ketoacidosis/life threatening complication of diabetes] (2022) on insulin presenting from home as a referral by pediatric endocrinologist [Z #1] due to hyperglycemia w/concern for DKA ...Over the past week, notes patient’s glucose was in the high 400’s, after which [Z #2] gave 25 units Humalog just prior to arrival. Also noted that [Pt #1] had ketones per meter at home. Has observed [Pt #1] appearing generally tired which is consistent with prior episode of DKA. [Pt #1] reports [Pt #1] feels general fatigue ...Ddx [differential diagnosis]: Suspect hyperglycemia in setting of inadequate glucose control at home given off home Lantus X4 days ...Plan: IVF [intravenous fluids], refill home meds. Labs. Endocrine clinic referral placed. Re-evaluation: CMP [complete metabolic panel lab] elevated glucose 268 ...UA [urinalysis] with glucosuria [sugar in urine] and ketonuria [ketones in urine]. VBG [venous blood gas] elevated lactate [determines if oxygenation is impaired] 2.3 otherwise no acidosis concerning for acute DKA. Dispo[sition]: Possible home with outpatient follow-up pending clinical improvement and with refills of home medication.” - Pt #1’s documented blood glucose levels were reviewed. One bedside glucose reading was recorded on 7/26/2024 at 10:22 AM (in triage). The result was 298 (high level - normal range 70-100). There were no subsequent blood glucose readings documented. -Pt #1’s orders were reviewed and included the following labs ordered and resulted: 7/26/24 at 10:21 PM: Basic Metabolic Profile; Lipase Level: Liver Enzymes; Urinalysis; Liver Profile; CBC with Differential; Blood Gas, Chemistry, Lactate, HgBs Venous; HBG A1c; and an ED CMP. The blood work results included: an elevated serum glucose (268/normal range 90-130) and an elevated lactate level (2.3/normal less than 2 millimole/per Liter). The urinalysis results included glucose >1000 (normal should not be detectable in urine) and high ketones 100 millimoles per liter (normal range is less than 0.6 millimoles per liter). Pt #1’s lab results included a moderate to large amount of ketones and a serum glucose greater than 200. The clinical record lacked notification to the endocrinologist on-call or to Pt #1’s endocrinologist (Z #1). -Pt #1’s orders also included sodium chloride 0.9 % 1 Liter bolus intravenous fluids that was initiated on 7/26/2024 at 10:34 PM and completed on 7/26/2024 at 11:37 PM. There were no further orders for Pt #1 during this ED encounter, including any orders for insulin; additional labs; or additional/recheck of bedside glucose. - An ED Note (dated 7/27/2024 at 12:14 AM), documented by the ED Resident (MD #2), included, “ ...Subjective: At time of sign out, states that feels well, would like food. Family at bedside asking when they may leave ...Assessment and plan: hyperglycemia. No evidence dka. Medications sent to pharmacy. Fu [follow-up] endocrine. After reviewing the patient’s history, physical and medical work-up I believe they are safe for discharge home at this time ...” - The ED Nursing Discharge Note (dated 7/27/2024 at 1:19 AM), documented by a ED RN (E #8), included, “[Z #2] was given discharge instructions. Advised to return to ED with new or worsening symptoms. Pt and parent verbalized understanding with no further questions.” Pt #1 received home prescriptions at discharge for insulin (Lantus and Humalog) and blood glucose monitoring supplies. A follow-up appointment with Pt #1’s endocrinologist (Z #1), was scheduled for 9/4/2024. 4. On 11/15/2024, the clinical record from Hospital B was reviewed. The record included that Pt #1 presented to Hospital B’s emergency department on 7/27/2024 at 8:37 PM. The ED physician’s history and physical included, “[Pt #1] with known diagnosis diabetes mellitus who presents with hyperglycemia and ketosis x 2[days]. Events leading to presentation at ED: Per MOC [mother of child], she has had difficulty obtaining patient’s long acting insulin due to just recently obtaining insurance. Has not had the long acting version for about four days. Yesterday, patient was feeling nauseous and complaining of abdominal pain, had NBNB [non-bloody, non-bilious] emesis. Was seen at ASH [outside hospital], where they gave fluids and said he was “ok to go home.” MOC reports that today AM patient had glucose of 116 so she did not give his insulin. [Pt #1] reported no appetite and ongoing nausea, so no additional insulin was given throughout the day. This evening, had another episode of emesis at which time MOC became concerned for DKA and called 911. EMS [emergency medical services] checked BG [blood glucose] and found to be in 400s ... In triage mental status was noted to be appropriate. Initial POC glucose was 590 ... Assessment/Plan: On evaluation, found to have dry mucous membranes, tachycardia, normal mentation. Labs notable for pH 7.1 bicarb 8, BG 559, HgA1c 14.3 [average blood sugar levels over the past 2-3 months -normal below 5.7%], elevated BHB [level of ketones in blood] and ketones on urine dip - most consistent with DKA. Endocrinology consultation obtained and admission recommended for additional management ... Plan: labs and fluids ... start insulin drip, admit to endocrinology, continue to monitor neurologic status, consider SW [social worker] consultation for family support.” The record indicated that consultation with endocrine services was completed in the ED; Pt #1 was administered medication for nausea; was started on an insulin drip; hourly glucose checks and neuro checks and additional labs were ordered; and Pt #1 was admitted to Hospital B on 7/27/2024 at 10:54 PM. 5. On 11/13/2024 at 9:10 AM, a telephone interview was conducted with an ED Resident (MD #2). MD #2 stated that Pt #1 was signed out to MD #2 on the night shift of 7/26/2024. MD #2 stated that Pt #1 was sent to the ED by Pt #1’s endocrinologist (Z#1) with concerns for DKA. MD #2 stated that MD #2 reviewed Pt #1’s labs and consultation notes. MD #2 stated that it was noted that Pt #1 had ketones in the urine; had glucose in the urine; and the blood work showed that the anion gap was high due to Pt #1 being a poorly controlled diabetic. MD #2 stated that a blood sugar of 298 is high, however, MD #2 felt good about discharging Pt #1 since Pt #1’s labs showed that Pt #1 was not in DKA, and the Pt #1 was wanting food. MD #2 stated that a patient wanting food would not be the presentation of a patient with DKA. 6. On 11/13/2024 at 9:40 AM, an interview was conducted with ED Resident (MD #3). MD #3 stated that MD #3 performed Pt #1’s MSE (medical screening exam) when Pt #1 presented. MD #3 stated that Pt #1 presented with concerns for possible DKA. MD #3 stated that there were concerns with Pt #1 getting home insulin. MD #3 stated that Pt #1’s parent (Z #2), did give short acting insulin prior to coming (approximately 2-3 hours before) due to the blood sugar being in the 400’s. MD #3 stated that type of insulin peaks in about 1-2 hours. MD #3 stated that when Pt #1 presented, Pt #1 looked generally tired and was hyperglycemic with a blood sugar over 200. MD #3 stated that there is a “Care Set” in the computer on how to manage hyperglycemia including giving IV fluids and insulin. MD #3 stated that the “Care Set” is an algorithm that determines the amount of insulin to give, based on the patient’s home regimen and the current blood sugar. MD #3 stated that after reviewing Pt #1’s labs, Pt #1 did have some factors for DKA, but there was not acidosis, and the pH was normal. MD #3 stated that if a patient’s blood sugar is high coming in, the patient’s blood sugar should be reassessed after the IV fluid bolus and insulin is given. MD #3 stated that a venous blood gas or blood chemistry would also be repeated in about 3-4 hours. MD #3 stated that this way, we (doctors) would be able to determine if the treatment was effective and if we (doctors) still need to monitor the patient. 7. On 11/13/2024 at 10:00 AM, an interview was conducted with the ED Triage RN (E #6). E #6 stated that Pt #1 was a Type 1 Diabetic who came in due to being out of long-acting insulin. E #6 stated that when Pt #1 came in, an accucheck (point of care/bedside glucose testing) was done and the blood sugar was 298. E #6 stated that a line (IV) was started on Pt #1 and the patient received a bolus of IV fluids and labs were drawn. E #6 stated that it is up to the doctor’s discretion if they want to give insulin. E #6 stated that if the initial blood sugar is high, it should be rechecked after 2 hours. 8. On 11/13/2024 at12:05 PM, an interview was conducted with the ED Pediatric Division Chair (MD #4). MD #4 stated that Z #1 sent Pt #1 to the ED with concerns about DKA. MD #4 stated that the patient came in needing a medical screening exam and received one. MD #4 stated that Pt #1’s (parent/Z #2), gave Pt #1 the short acting insulin (Humalog) as a pre-treatment prior to coming to the ED. MD #4 stated that when Pt #1 presented, orders included getting a point of care glucose; a urinalysis; a blood gas; and a bolus (IV fluids). MD #4 stated that the blood glucose was from 280-289 and the blood gas showed that Pt #1’s pH was normal. MD #4 stated that Pt #1’s bicarbonate level was normal. MD #4 stated that since Pt #1 was not in DKA, the goal should have been to ensure that the patient was back on the long-acting insulin for stability. MD #4 stated at that time of night (around midnight), when the patient was discharged, the means to get the prescription for the Lantus could have been difficult. MD #4 stated that Pt #1 could have received the Lantus while in the ED or even been admitted. MD #4 stated they (ED physicians) could have monitored the ketones more closely by getting a repeat urinalysis, prior to discharging Pt #1. MD #4 stated that also another blood sugar could have been checked to get more data. MD #4 stated that communication is key and that the ED physicians should have consulted with Pt #1’s endocrinologist. 9. On 11/13/2024 at 2:35 PM, an interview was conducted with Pt #1’s Endocrinologist (Z #1 - from outpatient clinic associated with hospital). Z#1 stated that Z #1 received a call from Z #2 stating that Pt #1 was out of Lantus. Z #1 stated that also Pt #1’s blood sugar was high and had large ketones at home. Z #1 stated that Z #1 advised Z #2 to take Pt #1 to the ED to get evaluated and to rule out DKA. Z #1 stated that Z #1 is aware that Pt #1 did come to Hospital A’s ED and was discharged home. Z #1 stated that Z #1 called Z #2 to follow up and found out that Pt #1 was being admitted to Hospital B for DKA (according to Z #2). Z #1 stated that, regarding Pt #1’s care in Hospital A’s ED, Z #1 would have ordered, if was consulted, Pt #1 to receive the Lantus. Z #1 stated that Z #1 would have also ensured that the ketones were clearing/going down. Z #1 stated that if there is acid build up in the body, the patient could become nauseous, have vomiting, dehydration, effect on the brain, and even become comatose.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39802 A. Based on document review and interview, it was determined that for 1 of 3 records (Pt. #1) reviewed for pain management, the Hospital failed to include the details of the pain assessed and failed to ensure timely interventions were implemented. Findings include: 1. The Hospital’s policy titled, “Pain Management Policy” (approved 11/24/2023), was reviewed and required, “Assessment of pain includes, but is not limited to: a. Location, b. Intensity, c. Quality, d. Frequency, e. Precipitating factors... Clinicians shall respond promptly to a patient’s report of pain...” 2. The clinical record of Pt. #1 was reviewed on 01/30/2024. Pt. #1 was presented to the Hospital’s emergency department (ED) on 12/27/2023, with a chief complaint of sore throat with fever. - The Nursing Triage Assessment, dated 12/27/2023 at 10:44 AM, indicated that Pt. #1 reported moderate pain rated at 5 (based on a pain scale from 0-10; 0 = no pain and 10 = worst pain); however, the record lacked documentation of the location, type, and other details of the pain reported. - The Medication Administration Record (MAR) indicated that Pt. #1 did not receive any interventions for pain until 12/27/2023 at 12:48 PM, over 2 hours later after the initial pain assessment. The record lacked documentation if Pt. #1 was offered pain relief at the time of the initial assessment. 3. An interview was conducted the Associate Director of ED (E#2) on 01/30/2024, at approximately 1:34 PM. E#2 stated that pain assessments in general are completed when the patients come into triage, and again when they come back to the station. E#2 stated that the patient should be assessed again before giving any pain medication and again an hour after administering pain medication. E#2 stated that the patient’s rating, location of the pain, intensity, etc. should be documented with each pain assessment. E#2 stated that the patient should be asked if they are satisfied with the pain level, and document that or any refusal of pain interventions in the record. B. Based on document review and interview, it was determined that for 1 of 5 records (Pt. #1) reviewed for intravenous (IV) line care, the Hospital failed to ensure that assessments were completed as required. Findings include: 1. The Hospital’s policy titled, “Nursing Documentation of Inpatient Care” (approved 12/26/2023), was reviewed and required, “Appendix C: General Units Nursing Documentation Requirements: ...Lines/Drains: ...Upon Initiation/Discontinuation...” 2. The clinical record of Pt. #1 was reviewed on 01/30/2024. Pt. #1 was admitted to the Hospital on 12/27/2023, with a diagnosis of pneumonia (lung infection). Pt. #1 had an IV placed in the right arm on 12/27/2023, at approximately 12:50 PM. The record indicated that the IV was removed on 12/30/2023 at the time of discharge (approximately 4:40 PM); however, the record lacked documentation of an assessment of the IV site at the time of discontinuation. 3. A telephone interview was conducted with Registered Nurse (E#8) on 01/30/2024, at approximately 2:17 PM. E#8 stated that IV sites should be assessed and documented every 8 hours and at the initiation and discontinuation.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 39802 Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition for Coverage 42 CFR 482.43, Discharge Planning. Findings include: 1. The Hospital failed to ensure that social workers were qualified to conduct discharge planning evaluations. (A-809)”

“DISCHARGE PLANNING-QUALIFIED PERSONNEL CFR(s): Any discharge planning evaluation or discharge plan under this paragraph must be developed by or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. This Standard is not met as evidenced by: 39802 Based on document review and interview, it was determined that for 2 of 4 social workers’ (E#7 and E#13) personnel files reviewed for discharge planning qualifications, the Hospital failed to ensure that the social workers were qualified to conduct discharge planning evaluations. Findings include: 1. The Facility’s Social Worker Job Description, dated 5/13/2021, was reviewed and included minimum qualifications: “...Must be licensed in the State of Illinois as an Licensed Social Worker (LSW)...” 2. The List of Current Social Workers as of 11/29/2023 was reviewed and indicated that 2 of 15 (E#7 and E#13) social workers were from a staffing agency. 3. The personnel files for E#7 and E#13 were reviewed on 11/30/2023 indicated the following: - E#7 was hired on 9/13/2022 as a social worker. The file included attestations signed on 9/27/2022 and 11/30/2023 from an agency representative that E#7 was licensed and met the minimum requirements for the job description of social worker. E#7’s file lacked a valid license as a social worker. - E#13 was hired on 3/15/2022 as a social worker. The file lacked a valid license as a social worker. 4. An interview was conducted with Human Resources Representative (E#14) on 11/30/2023, at approximately 12:45 PM. E#14 stated that the agency is responsible for ensuring that staff have valid licenses and meet the minimum requirements for the job based on the provided job description from the Hospital. E#14 stated that since the agency does the primary verifications of the licenses and degrees, the Hospital does not keep these on record. E#14 stated that the agency signs an attestation form annually to acknowledge that each staff meets the requirements of the job. 5. An interview was conducted with the Director of Inpatient Care Coordination (E#10) and Director of Regulatory (E#1) on 11/30/2023, at approximately 1:30 PM. E#10 stated that they had two social workers from agency and just found out that they were not licensed. E#10 stated that the Hospital requires the social workers to have a masters in social work and be licensed. E#10 stated that their employee badges have been revoked and they will no longer work at the Hospital as of now (11/30/2023). E#1 stated that both E#7 and E#13 came from the same agency.”