ur DIGESTIVE HEALTH & ENDOSCOPY CENTER, LLC. GOVERNING BOARD MEETING Meeting Minutes February 6, 2009 ‘Type of Meeting: Governing Board Meeting Meeting Facilitator: Dr. Taja Attendees: Dr. Taja-Facility owner and administrator; Jennifer Smith, RN-Interim Nurse Manager; Karen Sellers,RN-PRN staff nurse; Melanie Biedenhar,RN-PRN staff nurse; Heather Tucker-Nonelinical manager; Rola Taja-ad-hoc member 1. Call to order-Meeting was called to order @ 1:40pm I, Roll call-Done IIL. Approval of minutes from last meeting-Minutes from 1-20-09 meeting reviewed and approved IV. Open issues: Old business from 1-20-09 GB meeting a) Operating Agreement-Dr. Taja stated that the new agreement has not been finalized yet and will let the GB know when completed, bb). Pay raises-Cost of living raises were given to the DHEC employces mentioned ©) Cross-Training-Training has been completed with Dan Tussing now functioning as DHEC receptionist. He has also done some receptionist training with Keri Silver. Bonnie Gondola now functions only as transeriptionist for DHEC. 4) Policy/Procedure review-This is ongoing. Dr. Taja continues to review the manuals and will bring any suggested changes to next GB meeting. ©) Billing-Tricia James has been made an employee of DHEC and is now performing the billing functions for the Center. £) New Hires-2 nurses from SRMC Endoscopy have been hired as PRN staff nurses 1 of the new hires has ACLS-the RN who does not states she will be ACLS certified within the next 6 months. Another RN hire from SRMC Endo is imminent pending completion of employment forms V. New business: Agenda 2) New DHEC Hires-Dr Taja stated his intent to to hire 1-2 nurses on a part-time basis (not PRN) to do only recovery/discharge and who do not have to have GI Endo experience. Members discussed potentially placing ads in newspaper for help. hh) Jennifer Smith’s pending resignation-Resignation is to be effective 2-16 and she will assume a PRN staff nurse position. Dr. Taja and K. Sellers expressed theirdesire to have Jennifer stay in her position and Karen offered her assistance to Jennifer to help her in any way possible. Jennifer, again, stated how difficult it has, been to start and complete any management work due to only PRN staff availability. She stated that she has taken a PRN staff nurse position @ LMH and orientation begins the week of March 2, and that due to her stated commitment to LMH, she feels obligated to both DHEC and LMH. Karen did verbally agree to assume the Nurse Manager position for an INTERIM until a new hire could be made. Jennifer stated that she will help Karen in this position until the position is filled on a permanent basis. Jennifer also stated that she will think again about her decision to change to a PRN status or to stay in a part-time position with DHEC. i) Heather's assistance-Heather stated that she received an approval from Dr. Taja to hire a 3 day/week medical assistant for his office so that she can be more available to help DHEC management. i) New Hire Update-As stated above. 1 more nurse hire to be completed next week. k) ACLS requirement-Agreed by all present that only ACLS certified RN is to be in procedure room and @ least 1 present in admit/recovery areas until last pt. discharged. 1) Procedural Days-Dr. Taja stated that there will be no change in procedural days at this time. m) Operating Agreement Update-Dr. Taja stated changes still being made, will notify GB when complete, n) Time Clock-Heather stated has 2 computer programs which she is looking further into for payroll purposes. Will update accordingly. ©) DHEC Deficiencies (es per ODH/AAAHC)-Dr. Taja asked Jennifer to provide written documentation of tasks which she felt she needed to perform as Nurse Manager that had not been able to be done, or done fully, while DHEC was under different management, She stated that there were several things that needed started and/or completed to maintain compliancy with ODH/AAAHC standards and that she could not possibly complete them all without assistance. He stated that was why he was asking for a list, so that he could provide the assistance where needed. She stated that it would be more beneficial if he would wait for the AAAHC cited deficiencies when they send their decisional book, so that we would know mote specifically what issues need to be addressed first. P) QA Projects-Discussed various ideas for QA projects among the members: > (1)Correct med dosages/frequencies on admission sheet: (2)Nsg chart form changes; (3)Pt Satisfaction surveys-Jennifer stressed the need for the surveys for @ > (QA-these had been stopped last year after the 2° quarter. Dr. Taja agreed that surveys need to be done-agreed among those present that they will be presented to the pts as before-in a self-addressed/stamped envelope upon discharge. 2% Chart Review Update-Dr. Taja reviewed 4" Quarter 2008 charts for Dr. Kottapalli-He stated that 7 out of 15 charts had H&P’s which were dated from 2-5 yrs ago and did not have the update sticker on the H&P. Dr. Taja suggested that if Dr. Kottapalli ever requests credentialing privileges here @ DHEC again, that he should be denied dit this finding. Al! board members in agreement.1) Outside sign w/computer-generated signal-Heather stated needs to continue seeking help from tech support and stated that there has to be a designated phone line for the sign. Will continue to work on. 8) AAAHC survey outcome-Jennifer contacted Africa McWilliams and asked if any progress made on Correction Plan sent form CMS deficiencies. She stated that the Plan will probably not even be reviewed until the end of February. After this review, AAAHC will then complete the decision process. She stated that she would let DHEC know when a decision is made. t) DEA 222 forms update-Heather stated that she ialked to the DEA office in Cleveland and that she received instructions on what needed to be done to ensure legal compliance with med ordering. Will continue to investigate. u) Financial Statements for 2008-Dr. Taja stated that statements need to be completed by REA& Associates. Will continue to pursue. ¥) Outside doors occas being found unlocked/Alarm system occas found disarmed- Board discussed changing outside locks to building and changing code for security alarm, w) PRN Employees-Discussed making it mandatory for PRN staff nurses to work a minimum of Iday/month. Open issue, VI. Adjoumment-Meeting adjourned @ 3:30 pm