Deficiency in Posting Survey Results
Penalty
Summary
The facility failed to ensure that the last three years of survey results were posted in a location readily accessible to residents, family members, and legal representatives, as required by their policy. During the recertification survey, it was observed that the survey results were posted at the resident courtesy phone, which was not in plain view, and not in a location where individuals could examine them without having to ask. This deficiency was evident for five out of eleven residents attending the Resident Council meeting, who stated they did not know where to find the survey results without asking. The facility's policy on posting and availability of survey results and complaint investigations, effective January 2025, mandates transparency and regulatory compliance by posting the most recent survey results in accessible locations and making past reports available upon request. However, observations on multiple units revealed that the survey results from 2022 were not posted, and there was no documented evidence in the Resident Council Meeting Minutes that the location or postings of the survey results were discussed. Interviews with the Administrative Coordinator and the Director of Nursing confirmed that the survey results should have been posted since 2022, and the Administrator stated that the survey results are discussed in resident council meetings and on admission.
Plan Of Correction
Plan of Correction: Approved February 4, 2025 F577 483.10 Rights to Survey Results / Advocate Agency Information SS=C TAG I. The following actions were accomplished for the resident(s) identified in the sample: The social worker met with each resident identified and informed of the facility survey results posting location which is located on the first-floor lobby near the security desk. The facility ensured all 3 years of facility survey results were in the binder readily accessible to residents: #15, #49, #96, #29, #42. All residents indicated were informed by the social worker on 1/28/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility identified all residents, families, and legal representatives as having the potential to be affected. The residents will receive information of the location of the facility’s survey posting during resident council, care plan meeting and upon admission which is located on the first-floor lobby near the security desk. The facility has posted the location of the facility’s survey posting on the units, vestibule entrance and lobby. The Staff Educator will provide education of staff re: location of the survey posting. III. The following system changes will be implemented to ensure continuing compliance with regulations: The facility reviewed the Policy and Procedure titled Posting and Availability of Survey Results and Complaint Investigation to ensure compliance with regulations. The policy was revised on 1/8/2025. The Administrator provided in-service to the Director of Recreation, Director of Social Service on the facility’s policies and procedures entitled “Posting and Availability of Survey Results and Complaint Investigation” to ensure compliance. The facility will post the location of the facility’s survey findings on all units, the vestibule entrance of the lobby and by security desk. The residents will be offered to review the facility survey results during Resident Council. The facility’s survey binder will be reviewed quarterly by the Director of Therapeutic Recreation, Director of Social Services or Designee to ensure three years of facility’s survey results are posted and the residents are aware of survey results location. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The corrective actions will be monitored through quality assurance to ensure the same practice will not recur. The Director of Therapeutic Recreation and Social Services or Designee will develop an audit tool to monitor compliance with facility's survey posting results and ensure accessibility to all residents, families/designated representative. The audits will be conducted monthly for six months or until two quarters are at 100% compliance. The Directors of Therapeutic Recreation and Social Services or Designee will monitor monthly for six months ensuring three years of facility survey results are posted and accessible to all residents, families/designated representative is aware of survey result location on the first-floor lobby near the security desk. The Director of Therapeutic and Social Services/Designee will utilize an audit tool to assess compliance monthly and report findings to the Quality Assurance Committee for six months. Responsible: Executive Director/Administrator will be responsible for ensuring compliance.