Failure to Provide Timely Survey Information and Access
Penalty
Summary
The facility failed to provide timely and required information to the survey team upon entry and during the annual recertification survey, affecting all residents. Upon arrival, the survey team leader requested a facility census, resident list, and matrix from an RN, but these were not provided. Subsequent requests for the same information, as well as WIFI access, were made to the DON and NHA, with the full set of documents and access not provided until over an hour after entry. The WIFI access provided did not function throughout the survey, further impeding the process. The entrance conference worksheet, which outlines the required timeframes for document provision, was sent to the NHA, and the entrance conference was conducted, with the NHA confirming familiarity with the electronic file sharing platform. Delays continued as the NHA reported not having full access to the clinical portions of the EMR, and the DON was new and still acclimating to the system. Additional required documents, such as hospice agreements and dialysis contracts, were not provided within the required timeframe and had to be requested again. The DON later acknowledged that any unit manager should have been able to provide a census upon surveyor entry and agreed that the survey team was not provided timely documentation upon entry.