|Survey Date: 5/25/2010|
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 that 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 that 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 that the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.
V 0715 Medical Director responsible to ensure that all providers adhere to policies and procedures
The Medical Director failed to ensure that all policies and procedures were adhered to by all individuals that 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 CSS will have pre QAPI and QIFMM
meetings with the FA's X 6 months to
ensure all plans of correction are
documented correctly. 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 semiannually.
The Facility administrator (FA)
representing the GB will be responsible for
ensuring implementation and ongoing
compliance with this POC.