BCHR director Joe Newcomb and board chairman Dr. John Stanbery told the facility’s board of directors Tuesday that Medicare lifted its suspension of new admissions Monday and corrections have been completed for deficiencies noted in a survey by a state inspection team recently.
The only thing remaining for complete clearance of normal operations is confirmation by the state on BCHR’s Plan of Correction, or POC. This confirmation is being delayed for a few days because the person responsible for this action was out of the office this week for the holidays.
Perhaps having the most impact in this corrective process of “minor” deficiencies was the suspension of new admissions. The action has resulted in a drop in BCHR’s census (number of residents/patients) from around 190 to 180.
Despite this loss of revenue, the facility’s profit and loss financials were $14,000 over budget for the past month.
Most of the drop in census resulted from the fact Medicare regulations require that any resident who needs treatment or a procedure at a hospital or another facility be discharged from BCHR. Under the recent sanction, that individual could not be re-admitted to the county nursing home.
Newcomb and director of nursing Teresa Valdez emphasized all of the deficiencies were of a minor nature, and no residents were directly impacted or at risk.
Valdez said the most flagrant deficiency noted was that staff members had been keeping foodstuffs (used to assist patients with their medicines) in the same refrigerators as some medications.
This practice had been approved in the past (which was BCHR policy), but is no longer acceptable. This deficiency has since been corrected.
Administrators added that most of the deficiencies noted by the inspection team were documentation of policies which had been previously approved.
“Regulations don’t change that often,” said Stanbery, “but interpretation does. Still, it’s a good system and it helps us to improve,” he said.
“Now, our policies are very, very clear,” added Valdez of the corrective measures that have been taken and submitted to the state for approval.
“Everyone is now focused on the highest standards for our residents,” continued Stanbery.
The board chairman issued a statement of appreciation for the corrective action taken by BCHR personnel and administrators. “I want to thank the administration and all of the hardworking staff of BCHR for the daily care and dedication they give to each and every resident of this facility,” he said.
“We appreciate the state of Tennessee helping with yearly inspections that allow us to identify even the smallest areas where improvement is possible. Every board member has been supportive and active with input to help with this yearly review.
“I am happy that Bradley Healthcare is now admitting new loved ones from our friends and neighbors,” continued Stanbery. “We have (provided quality care) for over 50 years and look forward to 50 more years of the highest levels of care for Bradley County.”
Stanbery added that all of the deficiencies (noted by state inspectors) are subject to ongoing policy (at BCHR).
Valdez emphasized this was an opportunity for BCHR to improve. “Through this process I’ve learned a lot,” she said. “They told me, ‘We just want BCHR to get back to the business of business.’”
Newcomb, the facility’s director, expressed some frustration over the process of notification concerning the deficiencies noted by the state inspection team. “The newspaper (Cleveland Daily Banner) received notification before we did,” he said.
Newcomb added that when contacted by the Banner for comment, he could not make a statement because BCHR had not been notified of the specifics of the deficiencies.
It was pointed out that after the state inspection team leaves a facility, the state has 10 days to get back with specifics. This partially explains the lapse in communication, which allowed Medicare’s public notification to reach the Banner before BCHR was contacted.
This lapse in notification to BCHR officials resulted in some early confusion and concerns, especially with the general public and families of BCHR residents.
Valdez added that she and her staff had 23 days to take corrective measures. The corrective plan was submitted multiple times, due to disagreements with the language.
The state was notified Nov. 9 that corrections had been made, and a follow-up inspection team arrived Nov. 10 to confirm this action.
Valdez said the scope and severity of the deficiencies were all minor, with a majority of the violations involving one patient of the 49 that were randomly selected. Most of the deficiencies, she said, were interpretation of existing policies and documentation of implementation of these policies.
Board members had a few questions concerning the corrective measures undertaken by the BCHR staff, but most expressed agreement with the chairman’s statement.
Although the state inspection and correction of deficiencies were the major issues at Tuesday’s board meeting, some other issues were discussed.
- Wendy Beck discussed resident care, saying the county-owned facility has one opening for a registered nurse and four CMA positions.
Board member Cliff Eason asked how the positions are filled. Comptroller Sandy Brock said BCHR normally has applications on file to assist in filling staff vacancies. “If not, we’ll run an ad in the newspaper. We kind of grow on our own.”
Stanbery, the board chairman, said, “Most of our positions are filled from within.”
- The financial report was positive across the board. Net profit was $11,001 before depreciation. The budget had projected a net profit of $5,916.
Net revenue was $8,916 under budget, due to Medicare’s suspension of new admissions. This is expected to change with the lifting of the suspension this week.
Accounts payable were up $39,000 for the month, resulting from the expense of the annual audit and cost report, and cost of an intercom system.
- In a report on environmental services, it was noted that work continues on new televisions for the facility, wiring needs and window repair.