Every finding on record at Chadron Community Hospital Corp.

Chadron Community Hospital and Health Services is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

Licensed Practical (Vocational) Nurse CFR(s): 484.115(e) Standard: Licensed practical (vocational) nurse. A person who has completed a practical (vocational) nursing program, is licensed in the state where practicing, and who furnishes services under the supervision of a qualified registered nurse. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, the observation of the provision of care, and staff interview, the agency failed to ensure 1 of 2 Licensed Practical Nurses (LPN-B) providing skilled nursing services to agency patients, maintained an active license to practice in the State of Nebraska. This had potential to affect any of the agency’s patients assigned to LPN-B. The total patient census was 32. Findings are: A. Review of the agency policy and procedure titled, Renewal of Professional Nurse License, number C10-40-001, reviewed 8/2/22, revealed: 1. Licensed staff were to provide a printed copy of their renewed license to the agency’s Human Resource Department. 2. The department Director was to verify the license renewal of licensed staff when due. B. Review of the LPN Job Description, reference number 35-9050, revised 1/13/18, revealed LPNs were to be licensed in the State of Nebraska. C. Review of LPN-B’s personnel file revealed a copy of LPN-B’s license verification form from the State of Nebraska Public Health, Licensure Unit, Certification of Licensure, with an expiration date of 10/31/2023. D. Review of the agency’s Service Report, (a report generated from the agency’s electronic medical record system), for LPN-B, dated 1/24/24 at 3:22 PM, revealed, LPN-B provided services to agency patients on 47 days from 11/1/23 through 1/23/24. E. During the observation of provision of care for Patient 1 on 1/24/24, at 1:10 PM, LPN-B was observed providing skilled nursing services. F. During an interview on 1/24/24 at 3:10 PM, LPN-B confirmed their LPN license had expired on 10/31/2023. G. During an interview on 1/24/24 at 4:00 PM, Administrator/Registered Nurse (RN) Director, confirmed LPN-B did not have a active LPN license to practice in the State of Nebraska.