Delayed Provision of Facility Information and Employee Records
Penalty
Summary
The facility failed to provide the State Agency with timely access to requested facility information, which resulted in delays during the survey process. During the entrance conference, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked to provide a list of new hires, contracted employees, and an all-house employee list with hire dates. Requested new hire personnel files were not received until several hours after the initial request, and additional information regarding employee licensure, physicals, reference checks, and orientation was delayed further. Some documentation remained incomplete, requiring the surveyors to search through other files, which added more time to the review process. Additionally, the facility did not promptly provide complete annual educational records for employees, including the required 12 hours of annual training for nurse aides. Multiple requests were made for this information, and some records for nurse aides, therapy staff, and a registered nurse were still missing or incomplete after repeated follow-ups. The NHA asserted compliance but did not provide the requested documentation. There were also delays in providing an investigation for a resident and a staffing deployment sheet, with the requested documentation being provided an hour after the request. These repeated delays in providing readily available information hindered the survey process.
Plan Of Correction
F 0836 Facility will maintain new hire lists and training records in a central location monthly to ensure information is readily available. Copies of resident investigations will be maintained in the NHA office for ease of access during survey moving forward. NHA or designee will educate the HR Director on the new hire file checklist and maintaining employee lists. NHA or designee will educate the DON on maintaining annual education centrally and accurately for all staff for ease of review. ED or designee will educate the NHA on maintaining resident investigations. For auditing the timely provision of requested information to the surveyor team, the facility will audit the following areas: HR or designee will audit new hire files weekly for 4 weeks, then monthly for 2 months for compliance. Facility staff educator or designee will audit employee education weekly for 4 weeks, then monthly for 2 months for compliance. NHA will audit resident investigations weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.