Failure to Annually Review Resident Care Policies
Penalty
Summary
The facility failed to comply with the regulation requiring annual review and updating of resident care policies. Upon reviewing the facility's policies and procedures, it was found that the last documented review occurred on January 11, 2024. This indicates that the policies had not been reviewed for over a year by the time of the survey on January 16, 2025. During interviews conducted on the same day, the Nursing Home Administrator acknowledged the oversight and confirmed that the policies and procedures had not been reviewed and updated annually as required.
Plan Of Correction
1. The facility will complete a policy and procedure review on 8/1/24. The facility failed to be able to produce this form in a timely matter to the surveyor; however, at the time of the owner change, 8/1/24, new P & P's were reviewed and approved. 2. The facility will review policy and procedures annually. 3. The Nursing Home Administrator will be reeducated by the Regional Clinical Director/designee on reviewing policies and procedures annually and having a signature page with date. 4. The Nursing Home Administrator/designee will audit to ensure policies and procedures are reviewed annually. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.