The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TRI COUNTY HOSPITAL - WILLISTON 125 SW 7TH ST WILLISTON, FL Feb. 29, 2012
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview, the facility failed to assure that personnel are certified for 2 of 3 Medical Assistants (MA A and MA B) hired as Certified Nursing Assistants as required by Florida State requirements and the facility's own Policies and Procedures (P&P). The facility also failed to evaluate three of three Certified Nursing Assistants' competency as per the facility's P&P.
Findings:

1. Observation of the medical surgical floor on 02/29/12 at 9:00 AM revealed a board that indicates the census was five. Further observation of the board revealed the staff consisted of a Certified Nursing Assistant (CNA) named MA A.

A request was made on 02/29/2012 at 9:03 AM to see the job description for MA. The Human Resource (HR) Director and Director of Nursing (DON) both stated that there is currently no job description for MA. They both indicated that for the past month they had been discussing it, but they have not had the opportunity to create one. When asked, how MAs know what their duties are, the DON produced a document entitled, "Medical Assistant Responsibilities and Limitations". According to the DON, she goes over this information with the MAs and both MA A and MA C have reviewed it. The former DON was also involved in the rehiring of MA B as a MA, but they cannot find a competency was ever done on MA B.

Review of MA B's record revealed the employee is a Medical Assistant. Review of the employee file did not produce documents that employee was working in the hospital as Medical Assistant. Review of record shows an unofficial transcript that the employee had completed a course in Medical Assistant at a college in another state in 2007. No documentation of the diploma was found in the employee's record. An application for employment by Nature Coast Regional Health network, with the same address as Tri County Hospital, dated 09/04/2007 shows that the employee was seeking a position in phlebotomy. A payroll Input form was produced for this employee. A form for employee data and payroll data is for phlebotomist. A notice of employee separation was noted on 06/01/2010 indicating she was, "non-reliable". Review of MA B's record failed to reveal any written evaluation had been made of her performance once she started working as an MA.

Interview with the HR Director, Laboratory Supervisor, and Director of Nursing on 02/29/12 at 9:03 AM revealed that 2 named individuals were in charge of hiring when MA B was employed. These two individuals left the facility on 10/18/11 and the current HR Director stepped in to clean up the mess. Further interview revealed that one of the named individuals stole the facility's Policies and Procedures (P&P). The HR Director further stated that the facility is in the process of rewriting their policies and procedures. Further interview with the HR Director revealed that all rehires have old files pulled and new files started, the employees are re-contracted. The employees are treated as new employees with re-education and new files. According to Laboratory Supervisor, MA B was already working at the facility as a part-time phlebotomist when she hired her as a full time phlebotomist. According to the DON, MA B had informed her that she had worked at a named hospital as a Certified Nursing Assistant (CNA) and as a phlebotomist. She was hired full time to work in the laboratory (lab) on 1/18/10. She had to let MA B go because she was there, but there were many problems with her. By April the Laboratory Supervisor terminated her employment. Another former employee had the information regarding MA's termination, but the current HR Director was unable to find the information. According to the HR Director, she is unaware how MA B got rehired. In October MA B came with an Unofficial Transcript as a Medical Assistant (MA) and was rehired. The former DON was also involved in the rehiring of MA B as a MA. They believe she was rehired on 10/17/11 because that is the date she did her drug testing. According to the HR Director, the facility was unable to obtain MA B's official transcripts because there is a hold at the school. Further interview with the DON and the HR Director revealed the facility currently has two other MAs.

Review of the "Medical Assistant Responsibilities and Limitations" document revealed an MA can:
1. Prepare and file medical records and patient charts
2. Maintain medical records using standard filing system
3. Perform inventory control and ordering supplies
4. Maintain and adjust medical office equipment
5. Manage a petty cash drawer
6. Post service charges and payments
7. Gather community resources
8. Prepare and maintain appointment books
9. Sterilize, wrap and label instruments
10. Set up the examination room for the next patient
11. Record body measurements and vital signs
12. Prepare patients for their physical examinations
13. Assist with therapeutic procedures
14. Assist during simple surgical procedures
15. Prepare and administer medications as ordered
16. Draw up liquid medications and administer (most of) them as ordered
17. Collect and preserve bodily fluids, blood, and other specimens
18. Perform simple STAT screening test on collected specimens
19. Answer phones and relay patient's requests and questions
20. Type business correspondence
21. Transcribe dictated documents
22. Repeat and explain doctor's instructions (i.e. patient education)
23. Write the "S" and the "O" part of the SOAP note
24. Read laboratory or other results over the phone, but not interpret them
25. Respond to medical office emergencies, administer CPR and basic first aid
26. apply a topical numbing agent to the skin, such as an EMLA? patch
27. Fill out a laboratory requisition slip-and obtain physician's signature
28. Lay out and set up intravenous infusion therapy (IV) equipment
29. Place and initiate an IV line except* in states where the Medical Board prohibits it.

Interview with the DON at 10:00 AM on 02/29/12 revealed that even though she goes over what an MA is allowed and not allowed to do, by using the document provided, there are things they are not allowed to do in the hospital. When asked if the MAs are allowed to handle petty cash both the DON and the HR Director stated that they are not.

Review of MA A's file revealed she has a diploma and official transcripts from a named Florida college for MA. Further review of the employee file failed to reveal a competency for the MA. A notation on the file indicates that a competency was completed on 07/27/11 for her. Further record review revealed a document entitled, "[Certified Nursing Administration] Orientation Check off List" dated 07/27/11. No evidence was found in MA A record indicating that she was a Certified Nursing Assistant (CNA).

Interview with the DON and the HR Director on 02/29/12 at 11:35 AM revealed the facility's Governing Body has not addressed the MA job description issues as they have the midlevel staff. Registered Nurses and CNAs are licensed so they look at that. Further interview revealed the Governing Body has not narrowed down what an MA will be allowed to do in the facility. Right now MAs are treated as CNAs. According to the HR Director, MAs should be provided competencies upon hire and after the probationary period which is 90 days.

2. An electronic mail (e-mail) was received from the HR Director with an attached document of all of the employees hired. Review of the document revealed that both MA A and MA B were hired as CNAs not MAs. According to the document MA A was hired on 7/27/2011, the same day as the CNA Orientation Check List found in her file. According to the document, MA B was hired on 2/17/10, but no new hired date was listed on the spreadsheet.

Telephone interview with the HR Director on 02/29/12 at 2:27 PM revealed the document (spreadsheet) she sent was accurate. Further interview revealed that it is a spreadsheet created by the HR Director. According to the HR Director, the formed HR personnel filled it out when MA B was hired and placed her titled on the spreadsheet. The HR Director was unable to state why it said MA B was hired as a CNA without verification of her certification.

Another e-mail was received from the HR Director which was a print out from the Tennessee Department of Health: Licensure Verification. According to the document, MA B has an expired Nurse Aide certification. The print out indicates her certification expired on [DATE], 3 years prior to being hired as a CNA at Tri County Hospital.

Review of the P&P regarding rehired employees revealed, "All previous employees will fulfill the same requirements upon rehire." Further review of this P&P revealed "All employees who are rehired are required to fulfill their annual mandatory education requirement in addition to their employee health requirements." The last line of this P&P states, "All other employees that are rehired will be treated as new employees."

Review of the minutes from the facility's last Board Meeting, 12/07/11 revealed a list of physicians, physicians' assistance, and advanced registered nurse practitioner were accepted and approved by the governing body. Further record review failed to reveal any information regarding an MA's job description.

3. Review of 3 Certified Nursing Assistants (CAN) records (CNA A, CNA B, & CNA C) revealed they have all had their competencies completed. These competencies were completed by another CNA listed as the preceptor.
Review of the facility's policies and procedures (P&P) regarding competencies it states that all employees will have competencies completed yearly. Further review of the document revealed, "All employees will have a yearly competency performed by their individual Department Directors."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, record review and interview, the facility's Governing Body failed to ensure they ensured two employees (MA A & MA B) certifications before hiring them as Certified Nursing Assistants. The Governing Body also failed to ensure they had job descriptions and competency criteria's for Medical Assistants working in their facility. The Governing Body also failed to ensure to ensure that the hospital was financially stable to pay employees' salaries and vendors. These deficiencies resulted in the Condition of Participation for Governing Body not to be met.

Findings:Reference A 0023: Based on observation and interview, the facility failed to assure that personnel are certified for 2 of 3 Medical Assistants (MA A and MA B) hired as Certified Nursing Assistants as required by Florida State requirements and the facility's own Policies and Procedures (P&P). The facility also failed to evaluate three of three Certified Nursing Assistants' competency as per the facility's P&P.
Reference A 0073: Based on interview, the facility currently does not have an annual budget for 2012.
Reference A 0315: Based on interview and record review, the facility failed to have adequate resource allocated for sustaining the hospital's performance.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on interview, the facility currently does not have an annual budget for 2012.

Findings:

1. Interview with the Human Resource Director on 02/29/12 at 12:15 PM revealed she spoke to the person responsible for the facility's finances on the telephone and she stated that the facility's yearly budget has not been approved by the Governing Body. Further interview revealed she has not completed the budget yet to present it to the Governing Body.

2. Interview with pharmacist on 02/27/2012 at 9:10 AM shows that this pharmacist works three days a week, receives new orders for patients by having the nurses put the new orders on the door. The pharmacist states that an inventory is done each shift and he takes care of new orders. The pharmacist states that he was ordering supplies by telephone and that the supply company would not accept new orders until the facility's account is caught up. Further interview revealed that the facility is unable to get supplies until the facility gets financial straight.
Further review of pharmacy account revealed that an order was placed on 02/23/2012. The total bill was for 2162.76.

At 9:30 AM on 02/27/2012 a call by the pharmacist was made to the vender, who stated they would not take the order at this time and instructed the pharmacist to call accounts payable at the facility. Noted vender report for this particular vender show that on 02/27/2012 that balance due is 1586.97.

Interview via telephone with an Employee who is a paramedic in the emergency room 3 days a week was conducted on 02/27/2012 at 9:58 AM. The employee states that they are not hiring new paramedics and that he works only 3 days a week. Further interview revealed he had received payroll the last 2 weeks, and now is being paid weekly. According to the interview they had received half a check (Does not remember the dates) and then paid again half a week. On February 5th 2012 they did not receive a check and they were informed it had to do with labor board. Next check due Friday. The employees were promised to get paid for 02/05/2012 and did not receive it. States that they are out of splints and other supplies and he did tell Assistant Director of Nursing.

Interview with housekeeper on 02/27/2012 at 10:20 AM who stated that she received 3 checks, but she is still missing one check.

Interview with Environmental Technician on 02/27/2012 at 10:25 AM, revealed that since 12/2011 he has missing checks.

Interview with another housekeeper on 02/27/2012 at 10:28 AM revealed she is missing her first check, but was told she would be paid by June/ July of 2012. Likes her job at this facility.

Interview with Central Supply who is also the Assistant Director of Nursing on 02/27/2012 at 10:33 AM who states she has been working central supply since that person left. States that staff fills out orders for supplies, but that supplies are low due to low patient volume. Places orders on Thursday and Friday and has been on time does negotiate prices with the salesman. States has been paid weekly and on time. Missing a week of pay and told it went to labor board.

Interview with Business office supervisor on 02/27/2012 at 10:50 AM. Changed to another supply company and have been making deposits into the facilities account. Paying suppliers and payroll. States missing money from payroll last September and 2 weeks this year. Was told money was not coming that labor board was setting up something to repay bad wages.

Interview with Controller on 02/27/2012 at 10:55 AM who is responsible for payment to venders was conducted. States that money is tight paying most critical as dietary, lab and pharmacy supplies, linen supply, and medical supplies. Trying to keep on top of orders, not placing orders unless necessary. If needed bring supplies in from home. Payroll due for 12/24/2011 half the amount and all of payroll for 01/14/2012. States that labor board is setting up a schedule. Owe vender $6330 for several orders, states very few bills are due in 02/2012. Payment pending for pharmacy now 1783.15

Interview with Admission Clerk on 02/27/2012 at 9:40 AM who states has worked for 3 years at the facility. The facility owes 4 weeks of pay. Had been not paid the week of 01/29/2012 and 12/24/2011. Was told they would be getting paid, but it went to the labor board. Paydays are usually on Friday. States could lose house because did not receive pay last year.

Interview with laboratory technician on 02/27/2012 at 1:15 PM. States that has not received paycheck for first week in February. That there is a lab manager 3 days a week. According to the lab tech, it takes a while to get the results back. When they have a chemistry test order, a courier is called and sent to another lab to do, and this takes over 4 hours. The facility has run out of reagent numerous times.

Interview with Administrator on 02/27/2012 at 1:29 PM who states that on:
01/07/2012 no checks
01/14/2012 partial pay
01/21/2012 full pay
01/28/2012 full pay
02/03/2012 no check
02/10/2012 full pay
02/17/2012 full pay

Further interview with the Administrator revealed he would be able to make pay date for 03/02/2012, expecting 256,000 on 03/10/2012.

Interview with Physician who works in the emergency room and on the floor was conducted on 02/27/2012 at 1:40 PM. The Physician states that both Medicare and Medicaid have not paid the facility for 2 months. Discussed that in the near future that more Physicians were coming to the facility. States that he is owed money and he will get it.

Review of the payroll summary as of 02/24/2012 that payroll amount 40,810.27 is strictly for W-2 employees including Chief Executive Officer and does not include the emergency room Physician or Advanced Registered Nurse Practitioners (ARNP's), Physician Assistants (PA's) or technicians. Other staff payments are PA 2160.00 weekly for 4 weeks. Ultrasound Tech 750.00 weekly for 4 weeks.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on interview and record review, the facility failed to have adequate resource allocated for sustaining the hospital's performance.

Findings:Interview with pharmacist on 02/27/2012 at 9:10 AM shows that this pharmacist works three days a week, receives new orders for patients by having the nurses put the new orders on the door. The pharmacist states that an inventory is done each shift and he takes care of new orders. The pharmacist states that he was ordering supplies by telephone and that the supply company would not accept new orders until the facility's account is caught up. Further interview revealed that the facility is unable to get supplies until the facility gets financial straight.
Further review of pharmacy account revealed that an order was placed on 02/23/2012. The total bill was for 2162.76.

At 9:30 AM on 02/27/2012 a call by the pharmacist was made to the vender, who stated they would not take the order at this time and instructed the pharmacist to call accounts payable at the facility. Noted vender report for this particular vender show that on 02/27/2012 that balance due is 1586.97.

Interview via telephone with an Employee who is a paramedic in the emergency room 3 days a week was conducted on 02/27/2012 at 9:58 AM. The employee states that they are not hiring new paramedics and that he works only 3 days a week. Further interview revealed he had received payroll the last 2 weeks, and now is being paid weekly. According to the interview they had received half a check (Does not remember the dates) and then paid again half a week. On February 5th 2012 they did not receive a check and they were informed it had to do with labor board. Next check due Friday. The employees were promised to get paid for 02/05/2012 and did not receive it. States that they are out of splints and other supplies and he did tell Assistant Director of Nursing.

Interview with housekeeper on 02/27/2012 at 10:20 AM who stated that she received 3 checks, but she is still missing one check.

Interview with Environmental Technician on 02/27/2012 at 10:25 AM, revealed that since 12/2011 he has missing checks.

Interview with another housekeeper on 02/27/2012 at 10:28 AM revealed she is missing her first check, but was told she would be paid by June/ July of 2012. Likes her job at this facility.

Interview with Central Supply who is also the Assistant Director of Nursing on 02/27/2012 at 10:33 AM who states she has been working central supply since that person left. States that staff fills out orders for supplies, but that supplies are low due to low patient volume. Places orders on Thursday and Friday and has been on time does negotiate prices with the salesman. States has been paid weekly and on time. Missing a week of pay and told it went to labor board.

Interview with Business office supervisor on 02/27/2012 at 10:50 AM. Changed to another supply company and have been making deposits into the facilities account. Paying suppliers and payroll. States missing money from payroll last September and 2 weeks this year. Was told money was not coming that labor board was setting up something to repay bad wages.

Interview with Controller on 02/27/2012 at 10:55 AM who is responsible for payment to venders was conducted. States that money is tight paying most critical as dietary, lab and pharmacy supplies, linen supply, and medical supplies. Trying to keep on top of orders, not placing orders unless necessary. If needed bring supplies in from home. Payroll due for 12/24/2011 half the amount and all of payroll for 01/14/2012. States that labor board is setting up a schedule. Owe vender $6330 for several orders, states very few bills are due in 02/2012. Payment pending for pharmacy now 1783.15

Interview with Admission Clerk on 02/27/2012 at 9:40 AM who states has worked for 3 years at the facility. The facility owes 4 weeks of pay. Had been not paid the week of 01/29/2012 and 12/24/2011. Was told they would be getting paid, but it went to the labor board. Paydays are usually on Friday. States could lose house because did not receive pay last year.

Interview with laboratory technician on 02/27/2012 at 1:15 PM. States that has not received paycheck for first week in February. That there is a lab manager 3 days a week. According to the lab tech, it takes a while to get the results back. When they have a chemistry test order, a courier is called and sent to another lab to do, and this takes over 4 hours. The facility has run out of reagent numerous times.

Interview with Administrator on 02/27/2012 at 1:29 PM who states that on:
01/07/2012 no checks
01/14/2012 partial pay
01/21/2012 full pay
01/28/2012 full pay
02/03/2012 no check
02/10/2012 full pay
02/17/2012 full pay

Further interview with the Administrator revealed he would be able to make pay date for 03/02/2012, expecting 256,000 on 03/10/2012.

Interview with Physician who works in the emergency room and on the floor was conducted on 02/27/2012 at 1:40 PM. The Physician states that both Medicare and Medicaid have not paid the facility for 2 months. Discussed that in the near future that more Physicians were coming to the facility. States that he is owed money and he will get it.

Review of the payroll summary as of 02/24/2012 that payroll amount 40,810.27 is strictly for W-2 employees including Chief Executive Officer and does not include the emergency room Physician or Advanced Registered Nurse Practitioners (ARNP's), Physician Assistants (PA's) or technicians. Other staff payments are PA 2160.00 weekly for 4 weeks. Ultrasound Tech 750.00 weekly for 4 weeks.

Interview with the HR Director on 02/29/12 at 12:15 PM revealed she spoke to the person responsible for the facility ' s finances on the telephone and she stated that the facility ' s yearly budget has not been approved by the Governing Body. Further interview revealed she has not completed the budget yet to present it to the Governing Body.