cms_GA: 5987
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5987 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 520 | F | 1 | 0 | R5VO11 | Based on interview and record review, the facility 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 failed to develop plans of action with measurable goals and interventions to ensure that the identified concerns would not be repeated in the future. They failed to identify and correct concerns with, 1) the environment and housekeeping, 2) maintenance of essential equipment, 3) a properly functioning water system and 4) the lack of funds to pay their employees. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings include: 1. Review of the Statement of Deficiencies, the federal 2567 report dated 1/20/16 and the Plan of Correction (P(NAME)) for the revisit with a date certain of 2/4/16, revealed that the facility had failed to maintain the environment in a safe and sanitary fashion. 2. Observation of the kitchen on 2/4/16 from 4:00pm through 5:30pm revealed that the facility failed to maintain their essential equipment in safe operating condition. The facility ' s tilt skillet, stove/ovens, water faucets, walk-in freezer, dish machine, and convection oven were either missing parts, held together with electrical tape, or and not functioning properly. For additional information refer to F456. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00pm revealed that he did not have a policy and procedure relative to how to maintain the kitchen equipment effectively. The DM stated that he did attend the QA/PI meetings but the concerns about the kitchen equipment was not discussed. When interviewed about how he could ensure that these concerns would not continue in the future if they were not addressed in the QA/PI meetings, the DM stated he was unsure. Review of the 1st Quarter Monthly QA/PI Meeting Agenda revealed that 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 2:00pm 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 how the facility could ensure that the identified concerns would be corrected and not continue in the future if the MD did not attend the meetings with the IDT to ensure that interventions with measureable goals and time tables could be developed, the Administrator was uncertain. 3. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that this 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. For additional information refer to F493. During an interview with the MD via telephone on 2/6/16 at 11:30am revealed the some of the employees at this facility received checks that were returned due to insufficient funds. When interview about how he could ensure that this concern would not continue in the future if he did not discuss it with the QA/PI committee, the MD stated that he could not. He added that even his payroll checks were returned on occasion. The MD stated that he did not manage the facility ' s environment or payroll issues or discuss those topics in the QA/PI meetings, he stated that he only monitored the clinical aspects of this facility. 4. Observation of the kitchen on 2/4/16 at 4:00pm revealed that the dish machine had not functioned per the manufacturer ' s recommendations. Observation of the dish machine during operation for six separate trials revealed that the water temperature did not reach 120 degrees F during all six trials. The temperature ranged from 93-98 degrees F. For additional information refer to F371. An interview with the Dietary Manager (DM) on 2/4/16 at 4:45pm revealed that the facility ' s water system was not functioning properly, consequently the water in the dish machine could not reach the minimum temperature of 120 degrees F for either of the cycles. When interviewed about if he discussed the dish machine and the substandard water temperatures during the QA/PI meetings, the DM stated he did not. 5. Review of facility documentation and interview of residents and staff evidenced the facility failed to maintain water temperatures to provide a comfortable water temperature for residents in the facility to take a shower or bath. This issue was identified during a revisit on 1/20/16 and was to be corrected by a plan by the QA/PI program and completed by 2/4/16. This issue continued as identified in detail in F456. This issue continues to affect all 87 residents who resided in the facility at the time of the survey. Review of the plan of correction for facility issue of cold water in the facility for resident showers indicated QA would be a part of the plan to solve and monitor the problem and correct the issue with cold water. Review of the water temperatures revealed the plan implemented was not effective and failed to ensure residents had warm water for bathing. The QA committee failed to devise and implement a new plan of action to ensure residents had comfortable water temperatures. An interview with the facility Administrator on 2/6/16 at 2:30pm revealed that she could not locate any documentation either by record review, policy review, or review of the QA/PI committee meetings that demonstrated that the facility had a functioning and effective QA/PI program. The Administrator stated that she could not provide any documentation relative to how the facility planned to develop plans of action with measurable goals and time tables to ensure that the essential equipment, the water system and the employees paychecks concerns would not continue in the future. Review of the plan of correction for facility issue of cold water in the facility for resident showers indicated QA would be a part of the plan to solve and monitor the problem and correct the issue with cold water. Review of the water temperatures revealed the plan implemented was not effective and failed to ensure residents had warm water for bathing. The QA committee failed to devise and implement a new plan of action to ensure residents had comfortable water temperatures. | 2018-05-01 |