Purpose

To determine whether the New York City Health and Hospitals Corporation (Health and Hospitals) ensured that direct hire and temporary nurses were appropriately screened before they were hired and had policies and procedures in place to ensure that nurses are routinely monitored once hired. Our audit scope included all currently employed direct hire nurses as of May 2, 2017 and all temporary nurses as of August 1, 2017.

Background

Health and Hospitals is a public benefit corporation created by the New York City Health and Hospitals Corporation Act of 1969. Health and Hospitals, the largest public health care system in the nation, is a network of 22 facilities, including 11 acute care hospitals, 6 diagnostics and treatment centers, and 5 nursing homes, as well as more than 70 community-based primary care sites located across the City’s five boroughs. The network provides essential health care services to more than 1 million New Yorkers annually.

For the fiscal year ended June 30, 2017, Health and Hospitals reported total operating revenue of approximately $7.3 billion and total operating expenses of approximately $7.6 billion – personal service expenses accounted for $3.6 billion of this amount. As of May 2, 2017, Health and Hospitals employed 9,161 permanent (direct hire) nurses throughout its network. Additionally, as of August 1, 2017, it retained the services of 1,369 temporary nurses (see Exhibit A for a breakdown by facility). Health and Hospitals requires background checks on all direct hire and temporary nurses.

Background investigations of direct hire nurses are conducted by each facility’s Human Resources (HR) department if their annual salary is below $100,000, while the New York City Department of Investigations conducts background investigations of managerial nurses earning $100,000 or more per year. Further, all direct hire nurses employed after January 29, 2002 are required to have their background verified through fingerprinting. Vizient, Inc. (Vizient) is a contract labor manager that provides temporary nursing staff and manages agreements with staffing agencies on behalf of Health and Hospitals. These staffing agencies are responsible for conducting preassignment background screenings of temporary nurses employed by Health and Hospitals and for uploading supporting evidence to Vizient’s technology platform – Optimizer. The staffing agencies are also responsible for completing staff profiles attesting that the screenings were completed. The HR Directors at the facilities use Optimizer to ensure that all temporary staff have had the appropriate background investigation and clearance. Additionally, facilities are required to monitor nurse performance using evaluations.

For our audit, we reviewed files for a random sample of 200 direct hire and 98 temporary nurses from five Health and Hospitals facilities or organizations – Bellevue, Kings County, Lincoln, Gouverneur, and the Home Health Agency – to verify that these nurses were properly screened prior to being hired and were continuously monitored after hire.

Key Findings

• Of the 200 direct hire nurses in our sample, 41 (21 percent) had not been fingerprinted. Of these, 38 were hired before 2002 – when fingerprinting became required.
• Unlike for direct hire nurses, Health and Hospitals does not require fingerprinting of temporary nurses.
• For direct hire nurses, various background checks were not completed before hire.
• None of the facilities followed Health and Hospitals procedures for maintaining documentation of all screening checks, including retaining records supporting nurse candidates’ credentials. At each facility we visited, temporary nurses’ qualification and background screening documentation was not stored in a single, centralized location for ease of accessibility; some key documents had to be obtained from Vizient. Further, there was no evidence that Health and Hospitals reviewed background check documentation, as required.
• Performance evaluations were not completed for 25 direct hire nurses, including 24 at a single facility.

Key Recommendations

• Ensure all temporary and direct hire nurses are electronically fingerprinted so they can be monitored for potential criminal activity.
• Require facilities to complete and maintain documentation supporting that all background check requirements for nurses are met prior to their hiring.
• Ensure facilities maintain complete, readily available files for temporary nurses, and document evidence that staffing agencies’ background investigations of temporary nurses have been reviewed by Health and Hospitals officials.
• Require facilities to complete and maintain evidence of annual performance evaluations of direct hire and temporary nurses assigned for more than one year.

Other Related Audit/Report of Interest

State Education Department: Oversight of Nurse Licensing (2016-S-83)