601—696—4898 10:36:44a.m. Alliance 04—03—2014 516 PRINtED: 03124/2014 FORM APPROVED MSDH Health FacUlties Lbensure and Certification I (XI) PRDVIOER!SUPPLIER?CLIA - SThTEMENTOFDEFICIENCIES AND PLANOFCORRECTION DENTIFCATION NUMBER (X3) DAtE SURVEY COMPLETED C B AMNG__________________ MSIC7S NAFEOF PROVIDER DR SUPPLIER (X2) MULTIPLE CONSTRUCTiON A. BUILOJO 03/05/2014 STREEFADDRESS .CFYSWE. ZIP CODE 5000 HIGHWAY 39 NORTH ALLIANCE HEALTH CENTER (X4) ID PREFIX TAG MFRIIN MR 3gnI SUMMARY STATEMENT OF WUIENCIES D (EACH DEFICIENCY MUSTSEPRECEDED BYFULL PREFIX REGULATORY OR LSC DENTIFYINGNFORMATIO TAG I I M ooo 1 dial Comments PR0DERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TOTHEAPPROPRIATE DEFICIENCY) XS) COMPLETE DATE M 000 COMPLAINT INVESTATION #MS00012231 TI-B COMPLAINt WAS SUBSTANTIATED WITH DEFICIENCIES CITED. M1645 41.304 There shall be an adequate nunter... M1645 There shall be an adequate number of registered nurses readily available to patients requiring their services. A registered nurse must plan, supervise and evaluate the nursing care of each patient The staffing matrix will be adjusted to prli 30, reflect the minimum number of RNs 2014 required per shift based on census. \dditional RNs may be placed on the unit at the discretion of the nursing supervisor (based on the current patient population). This Statute isnotmetas evidenced by: Based on staffing schedule review, matrix staffing review and staff interview, the facility failed to ensure an adequate number of registered nurses readi’ available to patients reqiik their services on two (2) of 14 days reviewed, ‘here will be a sufficient number of duly icensed registered nurses on duty to plan, assign, supervise and evaluate nursing care, as well as to give patients the nursing care :hat requires judgment and specialized skills of a registered nurse. Findings include: Staffing levels will be monitored weekly by :he Directors of Nursing to ensure compliance with the staffing matrix. An interview wh the Nurse Manager on 315/14 from 10:15 am, to 1020 am, revealed that when the census is Ian on the Ged-psychiatric Unit, staffing is combined for the Journey Unit and the Geri-psychiatric. The facility’s Staffing Matrix used to determine when staffing Can be combined for these units and the number of staffing required. Nursing Supervisors and Directors of Nursing will be educated on the use and evaluation of the matrix. Review of the facility’s Staffing Matrix revealed that when the combined patient census for the Geri-psychlatric Unft and the Journey Unt B Msslsslppl State Department of Heailh liThE ABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE STATE FORM QT1I1 1 (X6)DATE foontlnuationsheet Iof2 601—6964890 10:37:0! am. AIllanc. 04—03—2014 616 VF%IN I tu;u.I id’IItuI4 FORM APPROVED MSDH- Heath Facilfties Lbensure and Certification STATEMENTOFDEFCIENCIES ANDPLANOFCORRECTION (XI) PROVIDERISUPPLIEWCLIA DENTIFICATIONNILiBER ALLLANCE HEALTH CENTER (X4)ID PREFIX TAG (X3)DATESURVEY COMPLETED BW,G MSIC7S NAME OF PROVIDER OR SUPPLIER (X2)MUUnPLECONSWUC11ON A BUILG:__________________ 03/05/2GM STREErADDRESS ,CIN,SWE, ZIPCODE 5000 HIGHWAY 39 NORTH MERIDN MS 39301 SUWW4ARY STATEMENT OF DEFICENC[ES (EACH DEFICIENCY MUST BE PRECEDED BY FIJI REGULATORY OR LSC D2JI1FYNG NFORMION) M1645 Continued From page 1 PRO V1DERS PLAN OFCORRECEON (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFESENCEDTOThEAPPROPRLqTE 0 PREFIX TAG (X5) CO9LETE DATE DEFICIENC M1645 13-14 patients, two (2) nurses are required to work the combined units cii the 11-7:00 shifts. Onty one nurse worked the 7-11 stilt on 2/20114. The Combined patient census atthattimewas 13. Oily one nurse worked the 7-llshft on 226114. The combined patient census atthattimewas 14 patients. These flndingswere dcussed with the Nurse Manager on 3/5/14 from 1:50 pm. tol 7 p.m.At thatfimeshe reviewed thestaffing and reported agreement with findings. 1ss1ss1pp1 Stale Department of Health SlATE FORM cmli IfcmWfluafienstwet Zaf2 PRINTED: 06)25/2014 FORM APPROVED MSDH - Health Facilities Licensure and Certification STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STREET ADDRESS. CITY. STATE, ZIP CODE 39 NORTH ALLIANCE HEALTH CENTER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED C 0310512014 B WING MSIC7S NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG M 000’ Initial Comments PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE M 000 COMPLAINT INVESTIGATION #MS00011 893 THIS COMPLAINT WAS SUBSTANTIATED WITH NO DEFICIENCIES CITED. Mississippi State Department of Health LABORATORY DIRECTOR’S OR PROVIDERISUPPLIER REPRESENTATIVES SIGNATURE STATE FORM 6699 TITLE DQU21 1 (XG) DATE If conlinuatiCfl sheet 1 of 1