Submit New Application

PETITION FOR REMOVAL OF FINDING OF NEGLECT FROM THE MISSISSIPPI NURSE AIDE REGISTRY Application

The purpose of the Petition for Removal of a Finding of Neglect from the Mississippi Nurse Aide Registry is to give the Nurse Aide an opportunity to request that a single entry of Neglect be removed from the MS Nurse Aide Registry.  The request cannot be made until one year from the date the finding of neglect was added to the name of the nurse aide on the Nurse Aide Registry. This process, including face-to-face meetings, panel interviews, or other procedures, should in no way be construed as a formal evidentiary hearing process. This process is consistent with the mandated provisions in 42 USC §1395i 3 (g)(1) and (d)(i) and (ii) addressing the removal of a finding of Neglect from the MS Nurse Aide Registry in limited circumstances. 
  • An individual with a finding of neglect placed on the nurse aide registry listing after January 1, 1995, may petition the Mississippi State Department of Health (MSDH), Bureau of Health Facilities Licensure and Certification (HFLC), for removal of the finding of neglect from their name one (1) full year after the finding is placed on the MS Nurse Aide Registry.
  • All petitions for removal of a finding of neglect must be submitted in the standard format provided by the MSDH/HFLC.
  • All petitions must be complete in format before being considered for review.
  • The petition will be reviewed and the nurse aide will be notified in writing of a final decision within 45 days of a complete petition.
  • The individual must provide the MSDH/HFLC with authorization for the release of any information deemed appropriate in conducting the review of the petition.
The MSDH/HFLC will consider a petition from a nurse aide for the removal of one finding of neglect upon a determination that:
  • The required time period has been met. A determination shall not be made prior to the expiration of the one (1) year period beginning on the date on which the finding of neglect was added to the name of the petitioner on the MS Nurse Aide Registry.
  • The employment and personal history of the nurse aide does not reflect a pattern of abusive behavior or neglect. For the purposes of this section, a pattern is defined as two (2) or more occurrences of abusive or neglectful behavior towards another individual that resulted in the potential for a negative outcome or an actual negative outcome to a resident.
  • The neglect involved in the original finding was a singular occurrence that resulted in a potential or actual negative resident outcome.
  • A background check, including a criminal history record check or report, revealed no history of mistreatment, including but not limited to instances of domestic abuse, the granting of a restraining order that was overturned, an adverse finding entered on any child abuse information index, or conviction of any crime including violence or the threat of violence.
INSTRUCTIONS:
The nurse aide must complete, upload images of required documentation, and submit this application, which includes the following:
  • Complete this application in its entirety.
  • Provide authorization for the release of any information deemed appropriate in conducting the review of the petition.
  • Provide a statement of why you believe you should be given the opportunity to have an adverse finding of neglect removed from the registry and your certification as a nurse aide reinstated.  (Your certification must be reinstated due to revocation with the placement of an adverse finding of neglect on the MS Nurse Aide Registry).
  • Provide a list of any rehabilitation or education pertinent to the job duties of a nurse aide that have been completed since the finding of neglect.
    • Attach a copy of your testing results to show successful completion of the competency and evaluation examination.
    • Provide the name of the course or rehabilitation program, the name of the instructor or contact person, the address of the facility where training was conducted, the contact number to that facility, the dates of attendance, and the certification received
  • Provide work history for the past two (2) years or since the finding of neglect was placed on the MS Nurse Aide Registry, including the names of employers, addresses, employment job titles and duties, and reason for leaving employment. 
    • Reference letters that speak to the individual’s character will also be accepted. Only one letter from a family member will be considered; however, a minimum of three (3) reference letters must be submitted.
  • A summary from each employer, as listed in subsection b, must be provided showing the nurse aide’s job performance, including dates of employment, job title, job duties, reason for leaving employment, behavioral conduct, and performance evaluations. The nurse aide must petition the prior employers to provide the MSDH/HFLC with these summaries, which are to be provided on the employer’s letterhead and signed and dated by the supervisor or employer.
  • The petitioner shall apply to challenge the Nurse Aide Competency and Evaluation Examination (with a code set up with NACES that will alert the necessary entities that the petitioner is registering to take the exam for Removal of a Finding of Neglect from the Registry – not expiration of certification). The Examination will be at the cost of the petitioner. Upon successful completion of the evaluation examination, the petitioner must provide a copy of the test results. If completion is unsuccessful, no review will be afforded to this petitioner and the petition for consideration for removal of the finding of neglect from the nurse aide registry will be denied.
  • Within two (2) weeks prior to the date of the petition, the nurse aide must submit to a criminal history background check conducted at the expense of the petitioner. If the background check was not completed within two (2) weeks prior to the date of the petition, the process must be completed again at the expense of the petitioner. The petitioner must name the MSDH/HFLC as the recipient of the background report.
  • Within forty-five (45) days of the receipt of the completed application, a panel will convene. The panel will be composed of three (3) individuals: HFLC Division Director, MS Nurse Aide Training Coordinator, and SQMT Certified Registered Nurse IV. A simple majority will be used for the final determination to remove or not remove the finding of neglect from the MS Nurse Aide Registry. The petitioner will be notified in writing by certified and regular mail of the panel’s determination within thirty (30) days of the panel review. 
If you have any questions, please contact MSDH at Antanikah.Robbins@msdh.ms.gov.
Address
AUTHORIZATION FOR RELEASE OF INFORMATION
MSDH FORM 678E - QUESTIONS AND STATEMENT
MSDH FORM 678E - REHABILITATION AND EDUCATION HISTORY
MSDH FORM 678E - WORK HISTORY
CRIMINAL HISTORY BACKGROUND CHECK
Affidavit
I attest that I have completed this application, including uploading any required documentation for the review of my petition.  I understand that:
  • This petition is specific to only one finding of neglect and does not include an opportunity to petition for removal due to subsequent findings of neglect.
  • This review requires a mandatory face-to-face interview.
  • I have authorized the release of any information deemed appropriate when reviewing the petition.
  • I shall apply to challenge the Nurse Aide Competency and Evaluation Examination (with a code set up with NACES that will alert the necessary entities that the petitioner is registering to take the exam for Removal of a Finding of Neglect from the Registry – not expiration of certification). 
    • The Examination will be at my own expense. 
    • Upon successful completion of the evaluation examination, I must provide a copy of my test results. 
    • If completion is unsuccessful, no review will be afforded, and the petition for consideration for removal of the finding of neglect from the nurse aide registry will be denied.
  • Within two (2) weeks prior to the date of the petition, I must submit to a criminal history background check conducted at my own expense. 
    • If the background check was not completed within two (2) weeks prior to the date of the petition, the process must be completed again at my own expense. 
    • I must name the MSDH/Bureau of HFLC as the recipient of the background report.
  • Within forty-five (45) days of the receipt of the completed application, a panel will convene. The panel will be composed of three (3) individuals: HFLC Division Director, MS Nurse Aide Training Coordinator, and SQMT Certified Registered Nurse IV. A simple majority will be used for the final determination to remove or not remove the finding of neglect from the MS Nurse Aide Registry. 
    • I will be notified in writing by certified and regular mail of the panel’s determination within thirty (30) days of the panel review.
  • Following a denial of the initial petition to MSDH/HFLC for removal of a finding of neglect, I may petition for a second consideration for removal twelve (12) months from the date of the Notice of Denial of the initial petition.  
    • The procedure stated within this policy must be followed with a second petition.  
    • The decision of the panel following the second petition is FINAL and cannot be appealed. 
    • If a new finding of neglect is placed on my nurse aide registry listing after the original finding of neglect has been removed, the new finding will remain on the registry with no opportunity to petition for removal. 
By Submitting
I hereby verify that I understand and agree with the statements contained herein and the above information is true and correct.