Lack of Governing Body, Incomplete Facility Assessment, and Nonpayment of Vendors Disrupting Food and Supply Deliveries
Penalty
Summary
The deficiency involves the facility’s failure to establish and demonstrate an active governing body that is legally responsible for setting and implementing policies for managing and operating the facility, including appointing a properly licensed administrator and ensuring an effective compliance and ethics program. Surveyors found no evidence of a governing board; the Regional Director of Operations (RDO) stated that there was no governing board, no names to provide, and that the owner was the 100% owner with no operating policy, and that “Mainstay” was described as the governing body without further clarification. The facility’s Compliance and Ethics Program policy was undated and unsigned, and although it stated the facility was committed to compliance and had designed, implemented, and enforced a compliance and ethics program with sufficient resources and authority, there was no evidence that this program was actually implemented. The RDO reported that policies came from a “compliance store” and confirmed there were no bylaws or operating policy, and continuity of business was described as being based on disaster preparedness. Surveyors also identified failures in facility assessment and financial/operational management. The facility assessment was incomplete, unsigned, and contained several blank or incomplete sections with many areas lacking supporting documentation, despite being reviewed with the QAA Committee. A Profit & Loss Budget Overview for a recent month showed a negative net income. Review of a U.S. Foods Customer Account Application showed that payment terms required timely payment of all charges, and the report notes that vendors were not getting paid, resulting in disruption in delivery of food and supplies to residents. Attempts to contact the owner and the accounts payable clerk by telephone and electronic communication were unsuccessful. The RDO indicated that the owner’s sister-in-law handled accounts payable and described reliance on corporate credit cards and a regional maintenance person with access to funds for emergency needs, but no formal governing structure, bylaws, or operating policies were provided to surveyors.
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