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F0756
E

Failure to Conduct Monthly Pharmacy Medication Reviews

Johnstown, Pennsylvania Survey Completed on 02-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that monthly pharmacy medication reviews were completed for seven residents over a period from August 2024 through January 2025. The facility's policy, dated January 2025, required the consultant pharmacist to provide a documented review of each resident's medication regimen at least monthly. However, there was no documented evidence of these reviews in the clinical records of the affected residents during the specified months. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of documented monthly pharmacy medication reviews. The Nursing Home Administrator indicated that the facility had switched pharmacies in January 2024 and assumed that the Director of Nursing was receiving the monthly reviews. This oversight led to the deficiency as the facility did not adhere to its policy and federal regulations regarding drug regimen reviews.

Plan Of Correction

Pharmacy medication reviews were completed for residents 16, 21, 23, 26, 33, 38, and 50. Residents who receive medications or treatments have the potential to be affected. Education was provided to the Director of Nursing on the process for maintaining records of pharmacy medication reviews. Staff educated on the process when pharmacy recommendations are received from pharmacy consultant: they are forwarded to attending provider. Once completed (approved, not approved) recommendations forms are kept in the resident record and a back-up copy in the pharmacy consultant binder. Monitoring will be captured through auditing pharmacy medication reviews. Audits will be conducted on 10 pharmacy recommendations monthly for 1 month, then 5 pharmacy recommendations monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.

See complete original report
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