cms_WV: 6031
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6031 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 492 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, policy review, and staff interview, the facility failed to comply with Federal, State, and local laws, regulations, and/or codes relating to health, safety, and/or sanitation by: a) failing to ensure the training requirements in section 4.1.c and 4.1.d of Series 85 of the Title 64 legislative rule for Alzheimer's/Dementia Special Care Units and Programs; b) failing to ensure WV statewide criminal background checks were completed per the timetable set by the Bureau for Medical Services (BMS) policy; c) failing to ensure [MEDICAL CONDITION] Screening was completed as outlined by the [MEDICAL CONDITION] Program for WV, based on the recommendation of the Center for Disease Control (CDC); and d) failing to ensure dietary employees maintained a valid food handler's permit as required by county regulations. This had the potential to affect all residents, employees, and/or visitors of the facility. Facility census: 94. Findings include: a) Section 4.1.c of Series 85 of the Title 64 legislative rule for Alzheimer's/Dementia Special Care Units and Programs requires 30 hours of documented training on the care of residents with [MEDICAL CONDITION] and related dementia for all employees prior to working in the unit; and section 4.1.d requires 8 hours of documented annual training to all staff. A review of the personnel files of 11 employees of the Alzheimer's/ Dementia Unit revealed Employees #56, #65, #104, and #112 had no evidence in their files of the required 30 hours of training. Five (5) of the employees (Employees #104, #7, #35, #79, and #87) had no evidence of the annual 8 hours of training for the previous year. b) The WV Bureau for Medical Services (BMS) policy required an up to date statewide criminal background check be completed for all current employees by March 1, 2014. Seven (7) of fifteen (15) employees reviewed had worked in the facility for more than three (3) years and did not have a current criminal background check. (Employees #20, #35, #45, #78, #79, #87 and #104. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. c) The [MEDICAL CONDITION] Program for WV, based on the recommendation of the Center for Disease Control (CDC) issued a directive on 02/01/2012, which addressed [MEDICATION NAME] screening of employees in nursing homes. The directive ended by stating: It may be the policy of your facility to administer a PPD to each employee and resident, and if so, you will need to continue that process to follow your own policy. A review of the policy entitled TB ([MEDICAL CONDITION]) Awareness Program derived from Healthcare Services Group and approved by the present Administrator on 03/14/14, stated under: 4. TB Skin test and screening a. We skin test all employees prior to beginning initial work assignment d. Negative Employees receive the same annual skin tests. A review of the employee health files of 15 employees revealed 9 of the employees (#7, #20, #35, #45, #50, #78, #79, #87, and #104) had not had annual testing as outlined in the facility policy. d) During an interview with the Administrator, Corporate Consultant, and Director of Nurses, at 10:15 on 08/13/14, the issues stated above and the sources of the requirements were discussed. The Administrator acknowledged the Alzheimer's annual training had not been done and said it had been overlooked by the new Director. She also stated they would make immediate arrangements for the background checks. She was continuing to check into the requirements for TB testing. e) Upon entrance, facility personnel were asked to provide evidence of food handlers permits, if the county in which the facility was located requires them. The food handlers cards were presented to the team leader on 08/04/14; no food handlers permits were presented for dietary aide Employee #6, cook Employee #20, and food service director Employee #82. Review of the schedule verified employees #20 and #6 were scheduled to work in the kitchen without current food handlers permits. All three (3) employees were observed working in the kitchen during random observations on 08/04/14 and 08/05/14. On 08/05/14 at 3:00 p.m., the food service director Employee #82, presented eFoodHandlers for State-of-the-Art Food Handler Training & Testing permits for himself, Employee #82 and cook Employee #20 which were both issued 08/04/14. On 08/07/14 an eFoodHandlers for State-of-the-Art Food Handler Training & Testing permit was presented for dietary aide Employee #6, with an issue date of 08/06/14. A telephone interview was conducted with the Harrison County Registered Dietitian on 08/13/14 at 3:00 p.m. The department does not recognize Internet programs including eFoodhandlers for State-of-the-Art Food Handler Training & Testing as a valid class for obtaining food workers permits. Employees must attend a class provided by the county health department. | 2018-05-01 |