On the Case with a Health Facilities Evaluator Nurse

Keeping staff and patients safe by enforcing state and federal regulations

Hallway with sign for the Los Angeles Department of Health Public Health Services

The streets outside the skilled nursing facility were quiet and dark as Bel and I pulled up at 2 a.m. We were there to investigate allegations of elder abuse, and I had so much adrenaline that I didn’t need coffee to keep me up.

“Immediate Jeopardy”

My coworker Bel had lured me into joining her on this late-night facility visit with the promise of a breakfast buffet after we finished our assignment, but by the time 10 a.m. came around, I had yet to see so much as a glass of orange juice and a blueberry muffin. Bel was still interviewing staff while I reviewed the facility’s records.

At 4 p.m., Bel called an “Immediate Jeopardy” (IJ). Under the federal regulations that govern all Medicare and Medicaid certified providers and facilities, an IJ is the most serious type of deficiency: a situation in which a facility’s noncompliance with health, safety, and/or quality regulations “has caused or is likely to cause serious injury, harm, impairment, or death” to a patient, resident, or client.

Identifying and correcting an IJ can literally be a matter of life and death.

While 2 a.m. facility visits like this are out of the ordinary — we typically work normal business hours — this is one example of the important work an HFEN does.

What Is an HFEN?

According to the California Department of Human Resources, the role of a health facilities evaluator nurse (HFEN) is to “conduct inspections, investigations, surveys, and evaluations of health facilities for conformity with licensing and certification requirements of the Department of Health Services and for compliance with State and Federal laws, rules, and regulations relating to medical care.”

In other words, we’re kind of like the nurse police.

California first established the HFEN role back in the early 1970s. While I’m new to the field of nursing enforcement, with barely two years of experience, I have met nurses who have spent 20 to 30 years with the department, with many stories to tell.

HFENs are responsible for proving or disproving allegations of regulatory noncompliance by a healthcare facility. We investigate allegations of abuse or neglect as well as quality of life, patient rights, and quality of care issues that affect patients.

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My job focuses on skilled nursing facilities, but the division I work for, the Health Facilities Inspection Division (HFID) of L.A. County Department of Public Health (LADPH), oversees the licensing and certification of a wide range of healthcare and ancillary health services in L.A. County, ranging from acute care hospitals to home health agencies and congregated living facilities.

Other counties also have their own HFENs, and some HFENs work for the California Department of Public Health (CDPH).

My Path

So, how did I get into this role?

In 2020, I had 24 years of dedicated service in the best place a nurse can work in a hospital: postpartum. I worked only two or three days a week, made lots of money, worked with beautiful babies, and got to see happy parents beaming with pride at the new additions to their families.

Unfortunately, the hospital where I worked was sold, which meant that on Aug. 13, 2020, I had to empty my locker, turn in my badge, and be escorted out of the building when my shift ended. It was not the way I had envisioned my last day of work!

My hospital experience was vast — med-surg, ER, pediatrics, psych, day surgery, telemetry, ICU, and postpartum — but after being laid off, I decided to try something different, something I’d never done before.

A friend talked to me about her role as an HFEN for the state. I tried to find articles about the role to help me decide if it was right for me, but there wasn’t even a wiki page describing what an HFEN was, and a Google search didn’t find much except the description in a job listing.

I decided to apply anyway, turned in my application, and got a call days later. In a month, I got my badge and became an HFEN for LADPH.

A Typical Workday

In L.A. County, an HFEN typically works four to five days a week, usually with nine-hour days. We work in the office three days a week, and twice a week we telework from home. Onsite and travel time varies, and is dependent on workload, but we can usually expect to drive to onsite facility visits one to three times a week, with a typical visit taking anywhere from one to six hours.

Nursing Education

When not onsite, we review records, conduct phone interviews, and type reports. We collaborate with peers and work closely with our senior HFEN, supervising HFEN, and program manager. In conducting our investigations, we also interact with patients, family members, and facility staff, ranging from administrators and physicians to dietary and housekeeping.

Working in enforcement requires us to stay on top of federal and state regulations, so we read a lot of emails and have meetings and classes on regulatory changes; we are always learning.

When “the State” Comes Calling

HFENs serve patients in an enforcement capacity, but we are nurses to the core, with the common nursing goal of improving patient outcomes.

Back when I worked in the hospital, I remember that anytime “the state” came calling, our department head would announce it on the overhead speaker system: ”Welcome the state health department. They are here in our building.” All the nurses would scramble to be on our best behavior. When I saw the “suits” in the hallway, I would hurry in the opposite direction. Now, I notice nurses doing the same thing to me when I’m surveying a facility.

Now that I’m on the other side, however, I can report that HFENs are actually more pro-nurse and pro-staff than most people assume. Think of it this way: When staff complains about certain things in a facility, their complaints may or may not be heard, but when HFENs bring up those same issues in the form of a writeup, the facility has to fix them.

Nurses should not be scared of HFENs because we all have the common goal of doing what is best for the patient. I encourage nursing staff to talk to us when we are in the field.

Is This Role for You?

If you’re looking for a change of pace, I invite you to look into the field of nursing enforcement. I honestly love being a HFEN, and it’s a path that I didn’t really know about before I got into it. I enjoy it because it’s so different from bedside nursing. I love the novelty of paperwork stacking up and writing reports on my laptop from home or office. I was pleasantly surprised with the investigative aspect of the job.

Computer literacy is a must for an HFEN, and you will need critical thinking skills, a willingness to learn, and good writing skills. You also need to be a team player.


California Department of Human Resources Health Facilities Evaluator Series job description: www.calhr.ca.gov

L.A. County HFEN positions: www.governmentjobs.com/careers/lacounty

CDPH HFEN positions: www.cdph.ca.gov

JOANNE MAINIT, RN, BSN, HFEN, has been a nurse since 1996 working in many different roles before joining the L.A. County Department of Public Health.

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