|Survey Date: 5/24/2010|
Regulation Title: CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR
Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Director. The facility's Medical Director failed to ensure providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records. The medical director also failed to be involved in the quality improvement process in ensuring medical errors were not repeated.
The facility failed to meet the following standards under the condition of Medical Director:
V 0711 Medical Director and QAPI.
The facility failed to ensure the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.
V 0715 Medical Director responsible to ensure all providers adhere to policies and procedures.
The Medical Director failed to ensure all policies and procedures were adhered to by all individuals who treat patients in the facility.
Facility Plan of Correction:
Members of the Governing Body (GB) have reviewed the Statement of Deficiencies (SOD) and formulated the Plan of Correction (POC). The standards under Condition: Medical Director (V710) that is not met as well as other standards contains specifics of corrective plans. The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures.
The Clinical Services Specialist (CSS) will have pre QAPI and QIFMM meetings with the FA’s X 6 months to ensure all plans of correction are documented correctly. Clinical Services Specialist (CSS) to attend QAPI meetings X 6 months to ensure Medical Director Participation. Administrative Assistant (AA) will attend QAPI meetings to record the meeting and POC’s developed by the IDT during the meetings.
The Governing Body will meet monthly x 3 to ensure compliance with POC. Further compliance to the POC will be reviewed during monthly QA meetings and reported to the Governing Body no less than semi- annually. The Facility administrator (FA) representing the GB will be responsible for ensuring implementation and ongoing compliance with this POC.