Initial Comments:
A focused fundamental survey was conducted February 26-27, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was eight and the core sample consisted of three individuals.
Plan of Correction:
483.460(j)(2) STANDARD
DRUG REGIMEN REVIEW
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The pharmacist must report any irregularities in clients' drug regimens to the prescribing physician and interdisciplinary team.
Observations:
Based on record review and interviews, it was determined that the facility failed to ensure that all quarterly drug regimen reviews from the pharmacist were completed and considered by the interdisciplinary team, including the physician. This applied to one (#3) of three individuals in the survey sample. Findings included:
Record review for Individual #3 was completed on February 27, 2024. This review revealed that there were four quarterly drug regimen reviews dated March 9, 2023, June 13, 2023, September 22, 2023, and December 6, 2023. This review further revealed that the March 9, 2023, pharmacist review stated, "Recommendations were made. Please see chart for recommendations." This review failed to reveal any documentation which stated the recommendations.
Interview with the assistant director of nursing (ADON) was completed on February 27. 2024, at 1:55 PM. The ADON confirmed the facility was unable to locate the recommendations made by the pharmacist on March 9, 2023. The ADON further confirmed that there was no documentation to indicate the pharmacist recommendations had been communicated to the physician or interdisciplinary team.
Plan of Correction:1. For Individual #3 pharmacy review recommendations were sent to the physician for review 2/27/24 and returned to the facility on 2/28/24. The IDT met on 2/29/24 and no changes were made per the recommendations. The Pharmacy review recommendations, physician's sign off, IDT meeting- evidenced by the sign off sheets was filed in Individual #3 medical chart.
SYSTEMIC UPDATES:
2. The policy on pharmacy review was updated on 2/29/24 to include that the physician needs to acknowledge, initial and date the pharmacy review and recommendations.
PROCEDURAL UPDATE:
The process was updated by the DON on 2/29/24 to reflect the following:
3. The pharmacy review recommendations with physician's acknowledgement to be emailed to the IDT for their information within one business day after receiving the physician' s acknowledgement via the sign off.
4. The IDT meets within 2 business days of receiving the pharmacy reviews to review the recommendations and agree upon implementation.
5. This information should be filed in the Medical Chart by nursing staff within 2 days of the IDT meeting.
6. Quarterly audit on all pharmacy review documentation, physicians sign off, IDT email to be completed by ADON and compliance be reported in the QM Quarterly Report continuously. DON will closely monitor compliance on a quarterly basis and address process gaps in an moving forward and ensure compliance and accountability in this area.
IDT team was educated on the above expectation 2/29/24 – 3/5/24
The above process has been implemented on 3/6/2024 under the oversight of the ADON/DON
483.470(i)(1) STANDARD
EVACUATION DRILLS
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at least quarterly for each shift of personnel.
Observations:
Based on facility provided fire evacuation drill documentation and interview, it was determined that the facility failed to ensure that an evacuation drill was completed on each shift of staff at least quarterly. This applied to one of four calendar quarters reviewed. Findings included:
A review of facility provided fire evacuation drill documentation for the previous 12 months was completed on February 27, 2024. This review revealed that there were two fire evacuation drills conducted on the first shift and one fire evacuation drill conducted on second shift in the fourth calendar quarter of 2023. This review failed to reveal any evacuation drills completed during the overnight shift in the fourth calendar quarter of 2023.
An interview conducted with the qualified other related conditions professional (QORCP) on February 28, 2024, at 1:20PM, confirmed that there were no fire drills completed on the overnight shift in the fourth calendar quarter of 2023.
Plan of Correction:A fire Drill calendar was created on 02/29/2024 to reflect completion of fire drills at ORC once per shift per quarter. The calendar marks the scheduled fire drills for each month and each shift to meet this compliance and is kept confidential. In addition, the facility will in-service the House Manager, QORCP, and the Assistant Director of residential on ensuring all fire drills to be conducted per the schedule without fail. This in-service will start immediately and will be completed by the end of the day on March 15, 2023. This process will be reviewed and monitored by the Assistant Director of residential once a month on going to ensure compliance and prevent future similar incidents. The Senior Director will review that the process is followed, and fire drills are completed and accounted for at the end of each month on going to ensure compliance.
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