Other·October 16, 2023

§483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is— (i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. §483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with §483.75(f). [§483.70(d)(3). On 9/27/2023 an unannounced visit was made to the facility to investigate a complaint about quality of care, administration, and residents’ rights. The facility’s governing body failed to ensure a licensed Administrator (ADM) was responsible for management of the facility and present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT) was performing administrative tasks without the presence of the ADM at the facility. As a result, there was an increased risk of inadequate management of the facility and affect the safety and overall well-being of the residents. On 9/27/2023 at 7:48 a.m., during an observation of the bulletin board, the ADM’s license was posted indicating ADM was the ADM of the facility. Registered Nurse 2 (RN 2), present at the time of the observation, stated the ADM was not in the facility. On 9/27/2023 at 8:44 a.m. during an observation, AIT provided RN 1 with the documents the surveyor had requested. On 9/27/2023 at 9:08 a.m. during an interview, Resident 4, who was oriented to person and place, stated he did not know who the ADM was. On 9/27/2023 at 10:05 a.m. during an interview, AIT 1 stated that the ADM was not in the facility and the Vice President of Operations (VPO), who was not in the facility, oversaw the facility. On 9/27/2023 at 10:16 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she worked in the facility five days a week. LVN 1 stated the AIT was the ADM. LVN 1 stated the ADM named on the posted license was in the facility maybe once or twice a week. LVN 1 stated the AIT had the role of the ADM as he was the one talking to the residents, families, and staff without the ADM. On 9/27/2023 at 10:39 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated she had not spoken or seen the ADM of the facility for a long time. CNA 2 stated the ADM came to the facility once or twice a month and the AIT handled the residents’ and families’ concerns without the ADM. On 9/27/2023 at 11:08 a.m., during a concurrent interview and record review, the VPO stated there were times the ADM and the VPO were not physically in the facility but were available via telephone call. The VPO stated the AIT could sign documents and function without the ADM present if the AIT consulted decisions with the ADM. A review of the Emergency Directors Phone Numbers, dated 9/20/2023, indicated that AIT was the ADM of the facility. On 9/27/2023 at 1:11 p.m., during an interview, the Director of Staff Development (DSD) stated she worked at the facility five days a week. The DSD stated the ADM was in the facility once a week or three times a month and the VPO was in the facility once a week or four times a month. The DSD further stated the AIT visited the residents, talked to the families, provided disciplinary actions, and counseled facility staff with the department heads as witness but without the presence of the ADM or the VPO. On 9/27/2023 at 2:18 p.m., during an interview, RN 1 stated that she worked five days a week. RN 1 stated the AIT 1 was the ADM and the abuse coordinator. RN 1 stated the ADM named on the license posted in the facility had not been in the facility for three weeks. RN 1 stated that the VPO was in the facility once every 2 weeks. RN 1 stated that the AIT 1 introduced himself to the residents and the families as the ADM of the facility and handled residents’ and families’ concerns, facility supplies and inventory, and disciplinary actions of facility staff without the ADM or the VPO. On 9/27/2023 at 3:13 p.m., during a concurrent interview and record review, the ADM’s job description was reviewed with the VPO and indicated that the administrative function of the ADM was to assist the Infection Control Coordinator and / or the committee in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks involving potential exposure to blood or body fluids were properly identified and recorded. The job description indicated that the ADM made routine inspections of the facility to ensure established policies and procedures were being implemented and followed and to assure that the facility had maintained a clean, safe, and sanitary manner. The VPO was asked if the ADM was able to fulfill these administrative functions based on the investigation findings provided by the surveyor and the VPO did not provide a response. On 9/28/2023 at 9:57 a.m., during an interview, the AIT 1 stated he was in the facility five to six days a week from 9 a.m. to 7:30 p.m. and on call as needed. The AIT stated the ADM and the VPO were available to come in the facility when requested. AIT stated he communicated with the ADM or the VPO through email, text message, and phone calls. The AIT 1 stated the ADM and the VPO were not able to stay in the facility the whole day and did not have to be in the facility if he (the AIT) kept them informed of his actions. The AIT further stated that he talked to the staff, residents, and families to listen and solve concerns without the ADM or the VPO present at the facility. A review of the facility’s policy and procedure titled, “Administrator,” last revised on 1/26/2023, indicated a licensed ADM was responsible for the day-to-day functions of the facility. The ADM was responsible for implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities. The policy indicated that a complete outline of the ADM’s duties and responsibilities was contained in his job description. The facility’s governing body failed to ensure a licensed ADM was responsible for management of the facility and present at the premises enough hours to permit adequate attention to the facility. The AIT was performing administrative tasks without the presence of the ADM at the facility. As a result, there was an increased risk of inadequate management of the facility and affect the safety and overall well-being of the residents. The above violations had a direct relationship to the health, safety, or security of all the residents in the facility.