cms_WV: 6033
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6033 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 520 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) Committee. The QAA committee failed to identify and act upon quality deficiencies in the daily operation of the facility in which it did have, or should have had knowledge. Criminal background investigations were not completed for all employees, [MEDICAL CONDITION] (TB) screenings were not completed, food service workers did not have approved food handlers permits as required by the Health Department of the county in which the facility was located, allegations of abuse or misappropriation of property were not immediately reported, and staff of the Alzheimer's/Dementia special care unit did not receive the required thirty (30) hours of training on the care of residents with [MEDICAL CONDITION] and other dementias, and the required eight (8) hours of annual training. These quality deficiencies have the potential to affect all residents residing in the facility. Facility census: 94. Findings include: a) During the annual survey there were five (5) deficient practices identified that should have been identified by the QAA committee, and plans of action implemented to correct these deficiencies. These were: 1. Criminal background checks were not completed for seven (7) of fifteen (15) employees whose files were reviewed. There was no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia. Employees #20, #35, #45, #78, #79, #87, and #104. -- The Bureau for medical service manual includes: 514.4.1 Employment Restrictions. Criminal Investigation Background Check (CBI) results which may place a member at risk of personal health and safety or have evidence of a history for Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to a 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 02/15/13. 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 three (3) years thereafter throughout 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 allowed the nursing facilities until 03/01/14, 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 01/01/13. -- The payroll/bookkeeper, Employee #38 stated, None of the tenured employees had an up to date statewide criminal background check that has been completed since their hire date, during an interview on 08/16/14 at 11:05 a.m. -- The administrator, Employee #52, was interviewed on 08/13/14 at 4:40 p.m. She acknowledged she was the facility's compliance officer and stated she stayed informed of changes in guidelines and requirements through continuing education programs, online training, trade journals and through her membership of the American College of Healthcare Administrators. However, she reported she was unaware of the State of West Virginia, Bureau of Medical Services requirement that all current employees have a criminal investigation background check by 03/01/14. 2) Annual employee [MEDICAL CONDITION] (TB) screenings and/or skin testing were not completed in accordance with the facility's policy for nine (9) of fifteen (15) employee records reviewed. Employees #20, #35, #45, #78, #79, #87, and #104. -- Review of the personnel files on 08/06/14 at 11:05 a.m., found no evidence of annual TB skin testing and an annual TB screening for the tenured employees. -- The facility TB policy states under section d Negative employees receive the same annual skin test. -- The payroll/bookkeeper, Employee #38, agreed the personnel files lacked any evidence of an annual TB screening, during review of the records on 08/06/14. 3) Three (3) of eleven (11) dietary employees did not have county health department approved food handlers permits. --Upon entrance, facility personnel were asked to provide evidence of food handlers permits, if the county in which the facility was located requires them. County food workers permits were presented for eight (8) of eleven (11) dietary employees on 08/04/14. On 08/25/14 eFoodHandlers for State-of-the-Art Food Handler Training & Testing permits were presented for the food service director, Employee #82 and cook, Employee #20. Both certificates contained an issue date of 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 local county Registered Sanitarian on 08/13/14 at 3:00 p.m. He reported the county 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 local county health department. 4) Three (3) allegations of neglect were not immediately reported in accordance with state law. The facility's grievances and complaint files for the period of 05/01/14 through 07/31/14, were reviewed on 08/12/14. Three (3) of the forty-six (46) complaints reviewed were allegations of neglect, and should have been reported immediately in accordance with state law. -- Resident #42, told the rehabilitation manager on 07/10/14, that the nurse aides made her sit up in her chair for 6.5 hours and would not listen when she requested to go to bed. The allegation was not reported immediately to the required State agencies. -- Resident #43, complained of an aide who had an attitude, and reported she had to wait a long time (30-60 minutes) for the call light to be answered by an aide. She also reported it sometimes takes 1-2 hours for the nurse to give her requested pain medications. The allegation was not reported immediately to the required State agencies. -- Resident #34, told the rehabilitation therapist on 06/23/14, that she did not get to sleep until 5:00 a.m., because she had been sitting in urine for hours and the aides kept turning her light off. The allegation was not reported immediately to the required State agencies. --The social worker, Employee #61, agreed all three (3) complaints were allegations of neglect and should have been reported immediately, during an interview on 08/13/14 at 3:14 p.m. 5) 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 and 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) Interviews regarding the quality improvement process of the QAA committee were conducted with the director of nursing (DON) on 08/13/14 at 10:30 a.m., and the administrator, on 08/13/14 at 4:40 p.m. When questioned on what quality deficiencies they had identified and implemented plans of correction, neither one mentioned any of the five (5) issues identified during the Quality Indicator Survey. | 2018-05-01 |