cms_GA: 5986
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5986 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 493 | D | 1 | 0 | R5VO11 | Based on record review, interview and review of policies and procedures, the facility governing body failed to ensure: 1) each facility employee was paid timely, 2) the Quality Assurance Performance Improvement (QA/PI) committee met quarterly and had the appropriate members present, and 3) develop effective policies and procedures. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that the facility might have some difficulties meeting their payroll obligations. Per the complainants, who requested to remain anonymous, the facility was in a financial bind , they were concerned that some of the employees might walk out and their payroll checks were being held. An interview with a Licensed Practical Nurse (LPN1) on 2/4/16 at 4:30 p.m. revealed that some of the nurses at this facility had not been paid per the facility policy and one LPN2 quit a few days previously due to non-payment. LPN1 added that many of the facility employees received their payroll checks late and soon after they deposited the checks, they were returned for insufficient funds. Review of the personnel file revealed LPN2 had written a note that stated, I (name of the employee) resign on 1/25/16. The note did not state why LPN2 resigned. During an interview on 2/5/16 at 2:30 p.m., Employee10 (E10) (an anonymous source) stated that she was aware of the hand written note in LPN2' s personnel file. E10 added that before LPN2 left the facility, she told E10 that she was resigning due to not receiving paychecks timely. An interview with a Nurse Aide (NA1) on 2/5/15 at 11:30 a.m. revealed the facility would hold the employee paychecks until after the bank closed for the day. NA1 added that their checks were supposed to be ready at 2:00 p.m. on paydays but the facility held their checks, until 4:00 p. m. When interviewed about why the checks were held until 4:00 p.m. on paydays, NA1 stated because that was the time that the bank closed for the day. NA1 added that the facility did not want the employees to go to the bank to cash their payroll checks because they knew that they did not have the funds available, so they held the checks until after the bank closed. When interviewed about what she would do if she needed her money on payday but could not cash her check, NA1 stated that she would have to go without. An interview with the Medical Director (MD) via telephone on 2/6/16 at 11:30 a.m. confirmed the employees at this facility received checks that were returned due to insufficient funds. The MD added that the facility would pay the bank fines that the employees accrued due to insufficient funds. Review of a document titled, Returned Check Fees dated 7/10/15 through 8/13/15 revealed that 21 employees accrued fees when their payroll checks were returned for insufficient funds. The fines ranged from 5 dollars to 117 dollars. An interview with the Regional Director on 2/5/16 at 12:30 p.m. confirmed that the employees received payroll checks that could not be cashed or deposited due to insufficient funds. The Director added that each time that occurred, the facility would reimburse each employee for the fines that the bank imposed on them. Review of an undated document titled, PAYCHECKS revealed the following information: Policy Statement .Name of the facility makes every attempt to issue accurate and timely paychecks. .Name of the facility makes every effort to ensure that employees receive their paychecks on time. However, circumstances may occur that prevent the company from meeting such obligations . The document did not have a Procedures section to include topics such as what day of the week the staff could expect to get paid, what time their paychecks would be available, or what to do if their paychecks were returned for insufficient funds. 2. The governing body failed to ensure that each member of the Quality Assessment and Performance Improvement (QA/PI)) committee attended the meetings and met on a quarterly basis to address concerns that had been identified throughout the facility. The facility could not provide any documentation that the QA/PI committee meetings were held at least quarterly since their recertification survey in August of 2015 or that the appropriate members attended the meetings. Review of the undated 1st Quarter Monthly QA/PI Meeting Agenda revealed the facility was to discuss the deficient practices that were identified during the 1/20/16 revisit survey, however review of the sign in sheet, revealed that the Medical Director (MD) did not attend the meeting. An interview with the Administrator on 2/6/16 at 2:00 p.m. confirmed that the MD did not attend the QA/PI meeting that was held on 1/29/16 with the Interdisciplinary Team (IDT). She stated that the facility had to hold a separate meeting with the MD at a later date. When interviewed about what the governing body did when the QA/PI meetings were not held timely or when the appropriate committee members were not present for the meetings, the Administrator was uncertain. Review of the policies and procedures revealed that the QA/PI policy was revised on 1/31/14 but it did not include important topics such as: a. What key personnel and facility staff were mandated to attend the QA/PI meetings. b. What the facility policy was relative to absenteeism during the QA/PI meetings. c. Who was responsible for ensuring that the QA/PI committee met timely. d. How to prioritize the concerns that were identified throughout the facility. e. What were the facility ' s procedures relative to how to identify new concerns throughout the facility. The policy included: QA/PI Meeting rev.1/31/14 Schedule a date/time convenient for your Medical Director. To assess the agenda go to: shared drive, clinical manuals, QA/PI manual, Monthly QA/PI meeting. The agenda/sign in sheet consist of 4 pages for each of the 4 quarters. Example-the first Quarter is for Jan, Feb, and March meetings to cover data from the prior month. (Dec., Jan, and Feb.) The designated QA/PI coordinator should access and save the agenda in their own facility Y drive in order to create a file later for each month ' s QA/PI data. (Make sure it is not saved in the G shared drive) Several days before the meeting, the QA/PI coordinator should print a blank copy of the agenda for the appropriate month, indicate who will provide the date before each section, copy and distribute. The collected data should be put in a saved file and named for the month. Input the ADC for the moth in each page and it will figure your percentages for you. Print and copy the completed form for the meeting attendees. One main copy should be signed by everyone at the meeting and kept on file. Note- Bold numbers in Standards of Practice column are (name of facility) thresholds. Each facility must set standards for the other areas and assess progress monthly. After the meeting the QA/PI coordinator should go back in to the saved agenda and input the new business and any action plans develop from the meeting. Items to bring to the Meeting: QA/PI agenda/sign-in sheet with data from the previous month Old Business (Action Plans in place with progress updates) Pharmacy Consultant Report Concern/Comment Summary Resident Council Meeting concerns with resolution summary QI/QM report (1 month and 6 month) Safety Meeting minutes Medical Record audit summary Business Office moth-end billing/triple check barrier summary Survey audits in progress Completed Nosocomial Infection Summary (Infection control Manual: Ch.2 p.4) An interview on 2/6/16 at 2:30 p.m. revealed the Administrator revealed could not locate any other policies and procedures relative to the QA/PI process, or any policies or procedures relative to the responsibilities of the governing body. The Administrator stated that most of the facility policies and procedures were on line and difficult to find. When interviewed about how the governing body reviewed and revised policies and signed that they had been reviewed, or how the staff would know how to perform their responsibilities and duties effectively if they could not retrieve and read the facility policies and procedures, the Administrator was uncertain. | 2018-05-01 |