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. This deficiency was identified through a review of facility policies and procedures, which lacked documented evidence of an annual review. During an interview, the Nursing Home Administrator (NHA) provided a sign-in sheet from a Quality Assessment and Performance Improvement meeting but admitted to not having a policy review date signature sheet. The NHA confirmed that the facility did not conduct the required annual review and update of policies and procedures.
Plan Of Correction
Immediate Action: Policy and Procedures were reviewed, and the signature sheet was updated. Education: The NHA and DON were educated by the chief nursing officer on the regulations for annual review of policies and procedures. Audits: Audits will be completed through the QA/QI process monthly times 2 months to ensure the signature sheet is complete.