Demonstrating Compliance in Employee Licensing

Jeannine LeCompte, Publishing and Research Coordinator

According to the Centers for Medicare & Medicaid Services (CMS), healthcare facilities must employ on a fulltime, parttime, or consultant basis those professionals necessary to provide the care and services the residents need. Professional staff must be licensed, certified, or registered in accordance with applicable state laws, and must meet the employment standards identified in their position’s job description. They are also responsible for maintaining their current licensure or certification and for providing appropriate proof to the facility in which they are employed.

Verification should be made that each newly hired employee possesses a valid license in good standing which is applicable to their position. Check with the state licensing database to review the potential employee’s licensing status.

Employers should require the employee to present an original license or certificate so that a file copy can be made. The employee must present the original―do not accept a copy.

The employer should routinely check the certificate against the state database, print the results, and save everything in the employee’s record. In addition, facilities should also document proof of ongoing licensure/certification for each employee who holds a license/certification by the state. Employers must always check the state database and print the findings upon hire and at the time of license/certification renewal to ensure they are not being presented with a false or invalid license or certification by the employee or contracted agent.

Employers can legally terminate an employee’s service if that employee:

  • Does not provide proof of renewed credentials within 10 days before expiration of those credentials so they can be verified with the appropriate state database.
  • Does not immediately inform the employer if they lose their licensure or certification or are placed on probation for any reason.
  • Does not immediately inform the employer if they fail their licensure exam. Employees must also notify employers immediately of licensure test results.
  • Fails a national and/or state credentialing examination two consecutive times (regardless of whether both failures occur during their employment).

If the employee is otherwise in good standing, in lieu of termination, upon mutual agreement, the employee can be reclassified to an alternate available position that does not require the license or certification, with an adjustment in pay.

CMS also states that if a nurse aid is found guilty of neglect, abuse, mistreatment, misappropriation of property, or exploitation by a court of law, they must have their name and this information entered into the state nurse aide registry. If a licensed staff member is found guilty of the above, they must be reported to their licensing board.

If there are actions against an employee by a court of law that indicate the individual is unsuited to work in a nursing home, then the facility must report that individual to the state nurse aide registry (if a nurse aide) or to the state licensing authorities (if a licensed staff member). Examples of convictions that may indicate unfitness to work in a nursing home include, but are not limited to, child abuse, sexual assault, theft, and assault with a deadly weapon.