DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 08/31/201? FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 555221 5- WING 03/31/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE SURPRISE VALLEY COMMUNITY HOSPITAL DIP SNF 741 MAIN STREET CEDARVILLE, CA 96104 ID SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) The re aration and/or execution of this 000 INITIAL COMMENTS 000 Plan of Correction does not constitute The following reflects the findings of the admission or agreement by provider of the California Department of Public Health during an . abbreviated standard survey for a complaint and I an entity reported Incident. I forth in the Statement Of dafiCienC -85. truth of facts alleged or conclusions set This plan of correction is prepared and/or Complaint: 537662 . Entity reported incident: 538015 executed solely as required. We have hereby submitted our plan of corrections far The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full survey. conducted on 6/29/17. Representing the Department: 26611. HFEN Deficiencies were issued at 490 for complaint 537662. No deficiencies were issued for entity reported incident 538015. F490 483.70 EFFECTIVE F490 2?10 435.627 sass Organizational Structure The hospital failed to have 483.70 Administration. Ia governing body that assumed Afacility must be administered in a manner that full legal responsibility for governing the enables it to use its resources effectively and hospital? operations to ensure that attain or maintain the highest quality health care was provided practicable physical, mental. and well-being of each resident. This REQUIREMENT is not met as evidenced in a safe environment. 1. Failure to submit an approved plan of correction (POCI for the recertification . gased on interview and record review. the sum? ending 6/29/16? . facility failed to administered their resources 2? Tall?j?re to have 5" effectively and efficiently in a manner to maintain mealcatlon 1113111611119 contra? the the highest well being of each resident, as Pharmacy availability; policies. and evidenced by; staff in place for the ordering, storage, and oversight of medications. Caused 1. Failure to pay travel staff agencies A. B, and having some medications not started in I a timely manner. 3. Failure to review and revise patient: LABOR TORY on REPRESENTATIVES SIGNATURE TITLE (st DATE . . x- 3 It - 17 aid-?K vest?? .c Any deficiency statement entKIg with an asterisk (I\denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide su? @fnt protection to the patients (See instructions.) Except for nursing homes the findings stated above are disclosable 90 days following the date of survey who her or not a plan of correction is provided. For nursing homes the above findings and plans of correction are disclosable 14 days following the data these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM Previous Versions Obsolete Event ID: BU0611 Facility ID: CA230000144 if continuation sheet Page 1 of 6 PRINTED: 08/31/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 555221 3- 08/31/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL SNF I CEDARVILLE, CA 96104 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES In PLAN OF CORRECTION (X5) DEFICIENCY MUST BE PRECEDED BY FULL FAEFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC EDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) care policies. F3490 (Son?nued page1 490 4.Failure to perform vaccinations screening 2. Failure to have an accurate accounting of debts due to one of four nursing staff vendors and one financial vendor on the board agenda dated 5/31/17?, had incorrect debts listed; and 3. Failure to have a medications (Drug) nurse assigned oversee the acquisition, receiving, and stocking of medications. Findings: 1. In an interview on 7 at 4:30 pm, Travel Nurse Agency A's Administrator stated nursing staff had to be pulled from the facility due to lack of payment and a lack of response by the facility's administrator. On 6/5/17 during the entrance interview at 12:30 pm, Admin Staff confirmed the facility had not paid AgencyA and the agency had pulled its staff from assignments at the facility as a result. Admin Staff reported that an alternate agency had been retained, Travel Nurse Agency to staff the facility licensed nursing needs, as the facility only had two licensed nurse on their Staff. Admin Staff further stated that Agency also did not get paid for their nursing services and the nurses assigned to the facility changed to Travel Agency C, which was currently staffing the facility's licensed nursing needs. On 6/5/17 at 3:30 pm, the Accounts Payable (AP) StaffA stated that she only paid accounts based on the instruction of the CEO because there was not enough in the facility accounts to cover all the expenses of the facility. When asked if Agency had been paid, AP Staff A reported that she was instructed by the CEO to cut a check and have the GB member sign it, then place in a drawer, on employees 5.Failure to ensure an interim administrator in place to cover leave of absence 6.Failure to pay travel staff agenci ES 7.Failure to have an accurate accounting of debts due to one of four nursing staff vendors and one financial vendors in board minutes incorrect. 8. Failure to ensure that medica rules and regulations for completior discharge summary. 9. Failure to routinely report a drug reactions and medication errort. Corrective action: 1.6/2016 POC has been completed on 2.5VHD is actively searching for an The DON is the pharmacy nurse until one can be hire alternative pharmacy, 1 staff of a dverse /8/17 acting and trained. A job posting for a pharmacy nurse was posted 8/4/17. A job description for a Pharmacy Nurse was written at 8/4/11 and will be approved by the Board meeti August 2017 the regular 3 Policy ?Policy Development and Rev written and approved by the MEC on and the Board on 7/25/17 4.Policy ?Immunization Policy for En Contract Employees, Volunteers, and Students" was revised and approved MEC on 8/3/17 and the Board on 5. The Board appointed a Board Membe (C on 6/6/17 an then hired a temporary CEO on 6/12/17 as outlined in the by A permanent Administrator was hired to act as Chief Executive Officer ng in iew? was /25/17 ployees, the FORM Previous Versions Obsolele Event ID: BU0611 Facility ID: CA230000144 Ifcon?nuauonsheetPage 2of8 PRINTED: 08/31/2017 DEPARTMENT OI: HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE Ex MEDICAID SERVICES OMB NO. 0938-0391 SWHEMENTOFDEHCENCES (XH PROVDERGUPPUEWCLM QEIDATESURVEY IDENHFEARONNUMBER: COMPLETED 555221 5- WING 08/31/2017 NAME OF PROVIDER OR SUPPLIER STREET CITY, STATE. ZIP CODE 741 N. MAIN STREET SURPRISE VALLEY COMMUNITY HOSPITAL SNF CEDARVILLE, CA 96104 ID PROVDERSPLANOFCORRECHON mm PREHX PREHX EACHCORRECWVEACHONSHOULDBE COMMENON TAG TAG CROSSREFERENCEDTOTHEAPPROPRMTE DNE on 8/4/17. F490 Continued From page 2 F490 6.Nurse Staff Agencies is in negotthions andruxtornanh. with to arrange a payment schedule since 7/31/17. The above described checks. numbers 27786, With a CPA on 5/28/17 to 27788, and 27899, dated 5/18/17, for nursing services provided 2/3 to 2/10/17. signed by GB Member were observed in the drawer of a desk in AP Staff A's office. On 6/5/17 at 12:30 pm. during the entrance interview, GB Member stated the GB had discovered recently that the CEO had paid old facility bills from 2013 and 2104. and had left bills for current operations unpaid. GB Member explained the GB recently became aware of specifics regarding the details of unpaid bills. GB Member further stated they did not currently have a plan to deal with the financial crisis faced by the facility. 2. On 6/5/17, the Governing Body minutes from 2/22/17 to the agenda of 5/31 /1 7 were reviewed. Each month contained an accounts receivable listing by vendor with the amounts due to each vendor. The 5/81/17 list inaccurately stated an amount due to Travel Nurse AgencyA as $15,865. The list of vendors failed to have two promissory notes (agreement to loan and borrow money with a structured payback), with Vendor reported. 2a. In an interview on 6/1/17 at 4:30 pm, Travel Nurse Agency A?s Administrator recalled [without being able to check her books during the call) the facility had a balance due of greater than $42,000 and the agency had sought legal assistance to get'paid. Travel Nurse Agency A's administrator reported that she had to pull the agency registered nurses from their assignments at the facility on 12/15/18 due to lack of payment and evaluate and help with the financial 8 Policy ?Physician Services? was wr approved by the MEC on 7/25/17 and on 7/26/17 9.Policy ?Adverse Drug Reporting" we revised on 8/3/17 and expected to be at the next MEC and Board meetings 1 New Adverse Drug Reporting form was rewritten. Continuous Monitoring: 1.A quality indicator was created td monitor that POC's are done in a tin manner and that it does not affect a the Board on 8/4/17 5 The Board appointed a Board member as Chief Executive OfficerfCEO) on 6 and the hired a temporary CEO on 6/1 as outlined in the Bylaws. A permane was hired on 8/4/17. Agencies is in negotia Administrator 6.Nurse Staff with to since 7/31/17. 7.8VHCD contracted with a CPA on 6/2 evaluate and help with the financial arrange a payment sche 8.Policy ?Physician Services" was wr and approved by the MEC on 7/25/17 a Board on 7/26/17 10 Policy ?Adverse Drug Reporting? revised on 8/3/17 and expected to bd at the next MEC and Board meeting in New Adverse Drug Reporting form was rewritten. s. itten and he Board 3 approved August. also ely ny and to act /6/17 2/17 nt tions dule 8/17 to s. itten nd the as approved August. also FORM Previous Versions Obsolete Event If continuation sheet Page 3 of 6 PWNTED10W3H2WY DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY ANDPLANOFCORRECUON IDENWFEAHONNUMBER: COMPLETED 555221 B. WING 08/31/2017 NAMEOFPROWDERORSUPPUER 741 N. MAIN STREET SURPWSEMMJEYCOMMUNWYHOSNIM. PSNF CEDARVILLE, CA 96104 ID mm PHEHX PREHX (EACHCORRECWVEAUHONSHOULDBE TAG REGULATORY DR LSC IDENTIFYING TAG CROSS-REPERENCED To THE APPROPRIATE DATE DEFICIENCY) Continuous Monitoring: 490 Continued From page 3 490 response from the facility in regards to requests for payment. During the entrance interview on 6/5/2017 that started at 12:30 pm with Administrative (Admin) Staff and GB Member E, Admin Staff stated Travel Nurse AgencyAwas owed $46,229.01, not $15,865 as reported to the GB. Admin Nurse Staff stated the CEO decided to write off amounts due to Travei Nurse AgencyA because of a quality of care infraction which resulted in a fine (State citation) from the Department. Admin Staff stated the CEO instructed the accounts payable staff to write off the payment for the nurses involved in the infraction and the fine amount. Review of the GB minutes did not include any record of this action being discussed or approved. The GB minutes and the facility Summary Aging Analysis. dated 6/5/17, indicated that Travel Agencies A, B, C, and had significant amounts due for greater than 91 days. 2b. During the entrance interview on 6/5/17 starting at 12:30 pm, Admin Staff stated the GB had not been provided with all of the vendor debt information. Admin Staff provided the surveyor with two promissory notes and instruction for payment, dated 4/26/17, issued by Vendor F, the first with payments due starting on 5/20/17 and the second with payments due on 6/20/17. When asked how she became knowledgeable of these notes, Admin Staff reported Vendor had called regarding the first payment not being made. Review of Vendor F's agreement with the facility indicated it was signed by the secretary of the GB 1.A quality indicator was created to that are done in a timely mann that it does not affect any patient resident care and will be reported starting 8/2017 by Administration an reported to Quality Assurance/Perfor Improvement Committee and then repor the Med Staff and Board of Directors quarterly by the Quality Assurance/R' Manager 2.A quality indicator was created to pharmacy oversight may and that it affect any patient and/or resident will be reported starting 8/ DON and reported to Quality Assuranc Performance Improvement Committee an reported to the Med Staff and Board Directors quarterly by the Quality A Risk Manager 3.A quality indicator was created to policy development and review and th does not affect any patient and/or care and will be reported st 8/2017 by Administration and reports Quality Assurance/Performance Improv Committee and then reported to the and Board of Directors quarterly by monitor er and and/or mance ted to monitor oes not are and 2017 by a/ i then of ssurance/ monitor at it esident arting to ement ed Staff the FORM Previous Versions Obsolete Event ID: BU0611 lfcon?nua?onsheetPage 4of6 PWNTED20W3WEWT DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 MTIPROVDERBUPPUEWCLM (XQIMATPLEOONSTRUCUON ANOPLANOFCORRECWON COMPHHED 0 555221 3- WING 08/31/2017 NAMEOFPROWDERORSUPPUER 741M. STREET SURPRISE VALLEY COMMUNITY HOSPITAL SNF MAIN CEDARVILLE, CA 96104 WMID ID PROWDERSPLANOFCORRECWON we PREHX PREHX (EACHCORRECWVEACHONSHOULDBE TAG REGULATORY OR 1.80 IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEHCENCW the Quality Assurance/Risk Manager Conhnuedeontpage4- f:490 5. A quality indicator was created to monitor on 4/21/17. The Vendor agreement included the GB resqution for this agreement which was adopted on 2/1/17. The GB minutes did not have a record of discussion or approval of non-payment of Vendor F. in an Interview on 6/6/17 at 5 pm, GB Member stated they had not noticed the promissory notes were not on the vendor list. GB Member further stated they (the GB) realized that they had trusted the CEO's reports, and had not done their due diligence to fully understand their financial situation. 3. On 6/5/17 at 12:30 pm, during the entrance interview, Admin Staff stated the facility Drug (Medication) Nurse had resigned the previous weekend and no one was currently filling that position. The facility did not have an onsite pharmacist and relied on the Drug Nurse position to oversee the acquisition, receiving, and stocking of medications. The Chief Nursing Officer (ONO) was also present for the entrance interview and stated she tendered her resignation 48 minutes prior. The GNU was not present during the survey after this comment. The facility did not have an administrative nurse appointed until the last hour of the investigation on 6/8/17. The CEO was unavailable during the survey due to a leave of absence. On 6/5/17 at pm, GB Member stated no interim CEO had been assigned. On 6/6/17 at 7:15 am, Registered Nurse (RN) A during an observation of the drug room, stated in a concurrent interview, since the drug nurse had availability of CEO/Administrator an it does not affect any patient and/o that resident care and will be reported starting 8/2017 by Administration an reported to Quality Assurance/Perfor Improvement Committee and then repor to the Med Staff and Board of Direct nance ted ors quarterly by the Quality Assurance/Risk Manager. A quality indicator was created to nurse staffing agencies and that not affect any patient and/or reside and will be reported startin by Administration and reported to On Assurance/Performance Improvement Co and then reported to the Med Staff a of Directors quarterly by the Qualit Assurance/Risk Manager. 7. A quality indicator was created financials and that it does not affe patient and/or resident care and wil reported starting 8/2017 by Administration and reported to Quali Assurance/Performance Improvement Co and then reported to the Med Staff a of Directors quarterly by the Qualit Assurance/Risk Manager. 8.A quality indicator was created to completeness of patient records and does not affect any patient and/or care and will be reported st 8/2017 by Medical Records and report payment it does at care 3 8/2017 ality nmittee nd Board 3 monitor ct any be by nmittee nd Board monitor that it esident arting ed to Quality Assurance/Performance Improvement Committee and then reported to the Med Staff and Board of Directors quarterly by Quality Assurance/Risk Manager. 9.A quality indicator was created to and Med errors are reported by pharmacist and that it does not affe patient and/or resident care and wil reported starting 8/2017 by Records and reported to Quality Assu the monitor ct any I be Medical rance/ Performance Improvement Committee and then reported to the Med Staff and Board Directors quarterly by the Quality Assurance/Risk Manager. of FORM Previous Versions Obsolete lfcon?nua?on she mpme5m6 DEPARTMENT OF HEALTH AND HUMAN SERVICES 08/31?2017 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB N0.0938-0391 STATEMENT OF DEFICIENCIES IXII PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BWDING COMPLETED 555221 8- WING 08/31/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE SURPRISE VALLEY COMMUNITY HOSPITAL SNF 741 MAIN STREET CEDARVILLE, CA 96104 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 490 Continued From page 5 490 left the facility's employment, RN A was unsure how the medications would get ordered. A policy was requested for medication acquisition but was i not provided during the survey. I I FORM Previous Versions Obsolete Event ID: BUOB11 Facility ID: CA230000144 If continuation sheet Page 6 of 6