Norwegian Christian Home and Health Center
December 19, 2018 Certification Survey

Standard Health Citations

FF11 483.10(f)(10)(iii):ACCOUNTING AND RECORDS OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2018
Corrected date: February 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that financial quarterly statements were provided to cognitively intact residents. Specifically, a cognitively intact resident stated that she does receive quarterly statements. This was evident for 1 out of 1 resident reviewed for Personal Funds (Resident #55). The facility Skilled Nursing Care Facility Admission Agreement signed by the resident on 10/17/14 documented You will receive a quarterly statement showing: a. Balance at beginning of statement period; date and amount of deposits and withdrawals; interest earned, if any; ending balance. The facility policy and procedure Resident Personal Funds Management dated 9/2018 documented A statement detailing all transactions on the account will be provided to the resident quarterly. The finding is: Resident #55 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. On 12/13/18 at 04:17 PM, an interview was conducted with the resident who stated she does not receive quarterly statements. On 12/14/18 at 04:11 PM, an interview was conducted with the Director of Social Services (DSS) who stated quarterly statements are given to residents who are alert and mailed to representatives of residents who are not alert. The social service department has not been involved in delivering or mailing quarterly statements; it is specifically done through the finance department. On 12/14/18 at 04:12 PM, an interview was conducted with the Chief Financial Officer (CFO) who stated all residents should receive a quarterly statement. On 12/14/18 at 04:12 PM, an interview was conducted with the Resident Trust Coordinator (RTC) who stated that as per the policy quarterly statements are mailed to the residents' families and residents residing in the facility are not provided with statements. The RTC stated he had no way of knowing which residents were alert and oriented and should receive their own statements. The RTC further stated that quarterly statements are mailed a week after being printed and there is no system in place for tracking when and to whom statements are sent. On 12/19/18 at 03:10 PM, a second interview was conducted with the RTC who stated that quarterly statements are mailed to resident representatives and usually all residents have representatives. If not the statement is then given to capable and cognitively alert residents. However, the RTC stated that he has been mailing the quarterly statements to resident representatives for the past fourteen years. 415.26(h)(5)(i)

Plan of Correction: ApprovedJanuary 14, 2019

1. Resident #55 was given the most recent quarterly statement of her account. 01/04/2019
2. Entire resident population will be reviewed. All those residents who are cognitively intact were given their quarterly account statements in person. Statements were provided to those who requested same. In addition, for those residents who are not cognitively intact, the residents designated representative was contacted and asked if they would like to continue to receive the resident?s statements. For those residents who do not have a designated representative, the Social Worker will pursue guardianship proceedings. 01/18/2019
3. The Director of Social Services and the Chief Financial Officer reviewed the facility?s policy and procedure regarding Resident Personal Funds and revised it as necessary to be in compliance with F568.
All Social Workers, Business office staff and Activities staff were inserviced by the Director Inservice Education regarding continued compliance with F568 as it pertains to the distribution of resident?s quarterly statements. The inservice focused on the following:
a. Identification of the residents who are cognitively intact
b. On a quarterly basis, all residents will be reviewed to determine his/her cognition level. If the resident?s cognition has changed, the Social Worker will instruct the Business Office to mail the statement to the designated representative. For those residents who do not have a designated representative, the Social Worker will pursue guardianship proceedings
c. Social Workers will provide a list of residents whose quarterly statements are to be mailed to the business office
d. Business office staff will mail statements and keep a tracking of statements mailed, including date of mailing
e. Statements will be delivered to the cognitively intact residents by the Activities Department. 01/25/2019
4. An audit tool was developed in order to monitor compliance with F568 as it pertains to the distribution of resident quarterly statements. The audit will be performed by the Director of Social Services as follows:
A sample of ten residents will be reviewed each month (5 cognitively intact and 5 whose statements are mailed) to ensure proper delivery of quarterly statements. Completed audits will be submitted to the Director of Quality Assurance for review. The results will be reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2018
Corrected date: February 11, 2019

Citation Details

Based on observations and staff interviews during the re-certification survey, the facility did not ensure that gloves were changed, and hands washed between tasks such as handling soiled and clean dishes which can contribute to cross-contamination. Specifically, a dietary aide was observed performing tasks and did not change gloves and perform appropriate hand hygiene between tasks. This was evident during the Kitchen/Food Service observation. The findings are: The facility policy Manual Washing and Sanitizing revised 5/14/18 documented to ensure that all pots, pans are cleaned and sanitized correctly to prevent food borne illnesses. On 12/17/18 at 02:37 PM, a Dietary Aide was observed during pots/pans washing. The aide was observed wearing long black rubber gloves that reached below the elbows. The aide removed an item from the first sink filled with a soapy solution, rinsed it off and placed it in the sink filled with a sanitizing solution. The aide then immersed the gloved hands into the sanitized water solution to remove the clean item which was then placed on a rack to dry. The aide did not change gloves when moving from dirty to clean items. On 12/17/18 at 04:21 PM, an interview was conducted with the Food Service Director (FSD) who stated the steps to wash pots/pans included washing the pots/pans in the first sink, remove from first sink and place them into the rinse sink also ensuring that the gloves are rinsed off as well, then placed the pot/pans into the sanitized water for two minutes. The FSD also stated it is too cumbersome to change the gloves. On 12/19/18 at 3:29 PM, a telephone interview was conducted with the Dietary Aide who has been employed at the facility for three years. The aide stated gloves are worn at all times during pot washing. The dietary aide also stated she was trained on pot washing when she first started working at the facility and has not been in-serviced or complianced related to pot washing. The dietary aide further stated she was not trained to change gloves once the dishes are cleaned and rinses off the gloves during the pot washing process. 415.14(h)

Plan of Correction: ApprovedJanuary 8, 2019

1. The aide involved was inserviced on proper pot washing techniques, including usage of gloves. 01/09/2019
2. All pot washing staff was observed while washing pots and no non-compliance was noted. 01/18/2019
3. The Food Service Director reviewed the facility?s process regarding the proper washing of pots and revised it to be in compliance with F812.
All Dietary Aides were inserviced by the Food Service Director regarding continued compliance with F812 as it pertains to the proper pot washing techniques. The inservice focused on the following:
a. When wearing gloves while performing pot washing duties, the aide will remove the gloves prior to moving pots to the rinse and sanitizing sinks. 01/25/2019
4. An audit tool was developed in order to monitor compliance with F812 as it pertains to the proper pot washing techniques. The audit will be performed by Food Service Director or Food Service Supervisor as follows:
The pot washing aide will be observed twice per week to ensure that proper pot washing techniques are being carried out. The results of the audit will be reviewed by the Food Service Director and reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2018
Corrected date: February 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically: 1) An oxygen tubing was observed touching the floor during two observations made during the survey, and 2) hand hygiene was not performed appropriately during a wound care observation. This was evident for 2 residents out of a sample 29 residents. (Resident #92 & Resident #103) The findings are: 1. Resident #92 is a resident who was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident is cognitively intact, requires extensive assistance of one person assist for transfer and is receiving oxygen therapy. During the survey on 12/17/18 at 09:16 AM and 01:02 PM, on 12/18/18 at 09:10 AM and on 12/19/18 at 08:53 AM, the resident's oxygen tube was observed touching the floor. On 12/19/18 at 08:44 AM, an interview was conducted with the Infection Control Preventionist who stated in-service trainings on donning, doffing, hand washing, and aseptic technique were provided to the staff. The ICP stated CNAs will monitor and inform the Nurse when the oxygen filter needs to be changed/washed. During the interview, the ICP and surveyor walked to the resident's room and observed part of the oxygen tubing on the floor and a faded inspection tag on the concentrator. The ICP confirmed that the tubing should not be on the floor and that staff should conduct rounds to ensure that the oxygen tubing is not touching the floor. Also stated by the ICP, the oxygen tube should be replaced and when not in use needs to be stored in a bag. Engineering was requested to inspect the concentrator's inspection tag and instructed to use a tool that will not fade, as per the ICP.
2. The facility Dressing Change Competency documented the following in steps #13 to #23: Wash hands. Don gloves and remove dressing. Wash hands, don gloves, cleanse wound with prescribed solution. Remove gloves, wash hands. Don gloves, apply treatment as per MD (Medical Doctor) orders. Cover with dry sterile dressing. Remove gloves, wash hands. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident with severe impairment of mental status, but able to make needs known and completely dependent on staff for all Activities of Daily Living. On 12/18/2018 at 11:30 AM, a wound care observation was conducted on Resident #103. The Clinical Nurse Manager Registered Nurse (RN #2) accompanied by a Certified Nursing Assistant (CNA#1) entered the room, introduced themselves and explained to resident what was to be done. Both staff washed their hands with soap and water and donned on gloves. Resident was re-positioned on the left side, pants lowered down, diaper was removed. Both staff washed their hands with water and soap and donned gloves. RN#2 cleaned the table with an antiseptic towel and covered the table with a sterile drape to create a clean field. RN#2 removed gloves, washed hands and donned new gloves. The RN proceeded to place supplies including 4 x 4 gauze, Normal Saline Solution (NSS), Collagen, Hydrogel and bordered gauze on the drape. RN#2 removed her gloves, washed hands and donned gloves before removing the soiled dressing. The wound bed was observed to be clean with no odor, with minimal drainage. RN#2 removed her gloves, washed her hands and donned clean gloves. She then proceeded to cleanse the wound bed with 4 x 4 gauze moistened with NSS several times. The periwound area was patted dry. RN#2 then applied Hydrogel treatment followed with Collagen treatment to the wound bed and covered the wound with bordered gauze. RN#2 did not change her gloves, wash her hands with soap and water or use alcohol gel after cleansing of the wound bed and before application of treatment. RN#2 was immediately interviewed after the procedure and stated I thought I washed my hands and put on new gloves. 415.19(b)(4)

Plan of Correction: ApprovedJanuary 8, 2019

F880 ? Oxygen Tubing
1. The oxygen tubing was immediately discarded and replaced.12/19/2018
2. All other residents on oxygen were observed and no oxygen tubing was touching the floor. 01/04/2019
3. The Director of Nursing Services reviewed the facility?s policy regarding the proper administration of oxygen and found it to be in compliance with F880.
All Licensed Nurses were inserviced by the Director of Inservice Education regarding continued compliance with F880 as it pertains to the proper placement of tubing during the administration of oxygen. The inservice focused on the following:
a. When placing a nasal cannula or mask on a resident receiving oxygen, the nurse must ensure that the tubing is not touching the floor
b. If the tubing is found to be touching the floor, it shall be replaced immediately
c. All issues should be reported to the Nurse Manager. 01/25/2019
4. An audit tool was developed in order to monitor compliance with F880 as it pertains to the proper positioning of tubing during the administration of oxygen. The audit will be performed by the Nurse Manager as follows:
A 10% sample of residents who receive oxygen will be reviewed each month to ensure proper positioning of tubing during oxygen administration. The results of the audit will be reviewed by the Director of Nursing Services and reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing

F880 ? Dressing Change
1. The nurse who performed the procedure was immediately informed of the concern raised by the surveyor. 12/18/2018
2. All dressing change procedures were observed and no issues of non-compliance were noted. 01/11/2019
3. The Director of Nursing Services reviewed the facility?s policy regarding the proper dressing change procedure and found it to be in compliance with F880.
All Licensed Nurses were inserviced by the Director of Inservice Education regarding continued compliance with F880 as it pertains to the proper procedure to follow when performing a dressing change. The inservice focused on the following:
a. The Dressing Change Competency was reviewed with all licensed nurses.
b. All licensed nurses were instructed to follow the competency step by step
c. Any issues should be reported to the Director of Inservice Education. 1/25/2019
4. An audit tool was developed in order to monitor compliance with F880 as it pertains to the proper steps to be followed when performing a dressing change. The audit will be performed by the Assistant Director of Nursing as follows:
A 10% sample of residents who receive dressing changes will be reviewed each month to ensure proper infection control practices when performing a dressing change. The results of the audit will be reviewed by the Director of Nursing Services and reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2018
Corrected date: February 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all medications and biologicals were stored and labeled properly. Specifically, one opened insulin pen was observed in the Medication cart dated 4/24/18. This was evident during observations conducted for the Medication Storage Task. (Third Floor) The finding is: On 12/17/18 at 10:31 AM, during the medication storage task with LPN #1 a opened [MEDICATION NAME]pen was observed with a hand written open date of 4/24/18. LPN #1 stated that she was unable to provide information about the insulin pen and would inform the Nurse Manager. On 12/18/18 at 05:53 PM, an interview was conducted with LPN #2 who stated insulin pens are dated once opened. LPN #2 stated the date, initials and shift preferably should be documented on the insulin pen. Before administering medication to a resident, LPN #2 stated the expiration date is reviewed and insulin is discarded within thirty days of opening. On 12/19/18 at 01:30 PM, the Nurse Manager was interviewed and could not determine a start date for the insulin pen. On 12/19/18 at 03:43 PM, the Assistant Director of Nursing Services (ADNS) was interviewed and stated the insulin pen was dispensed from the pharmacy in (MONTH) (YEAR). The ADNS also stated that insulin is labeled and dated when it is opened. The ADNS further stated that the date was written poorly by the nurse and that the insulin pen was opened on 11/24/18. 415.18(e)(1-4)

Plan of Correction: ApprovedJanuary 8, 2019

1. The insulin pen in question was immediately replaced by a new pen, which was properly dated. 12/19/2018
2. All insulin pens in use in the facility were reviewed and all were found to be properly dated and in compliance with F761. 01/04/2019
3. The Director of Nursing Services reviewed the facility?s process regarding the proper dating of insulin pens when opened and found it to be in compliance with F761.
All Licensed Nurses were inserviced by the Director of Inservice Education regarding continued compliance with F761 as it pertains to the proper dating of insulin pens when opened. The inservice focused on the following:
a. Whenever an insulin pen is opened it must be immediately dated with that day?s date
b. Nurses must take care to write legibly when dating the pens
c. Dates will be written in the following format: month/day/year.
d. Any discrepancies should be reported to the Nurse Manager 01/25/2019
4. An audit tool was developed in order to monitor compliance with F761 as it pertains to the proper dating of insulin pens when opened. The audit will be performed by the Nurse Manager as follows:
All residents who use insulin pens will be reviewed weekly for four weeks, then once each month to ensure proper dating of insulin pens when opened. The results of the audit will be reviewed by the Director of Nursing Services and reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2018
Corrected date: February 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews , the facility did not ensure that residents/families were informed and provided with written information concerning the right to accept or refuse medical or surgical treatment and at the resident's option to formulate an advance directive. Specifically, Resident #122 is cognitively impaired and has a family member involved in the care of the resident. A review of the resident's medical record did not have evidence that the issues concerning advance directives were discussed with family members, or that family members were provided with such written information. This was evident in 1 of 29 sampled residents. (Resident # 122). The facility policy on health care proxy /advance directives /DNR dated 08/20/2013 and revised on 06/20/2018 documented the following: It is the policy of the facility to inform all residents of their rights to formulate advance directives, including a heath care proxy and MOLST form with do not resuscitate order as per wishes. The facility's social work department provides ongoing education to all residents and/or health care agents/ families/ representatives/or surrogates at resident and or family council meetings and through mailing to families. The finding is: Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set 3.0) most recent quarterly assessment dated [DATE] identified the resident as severely cognitively impaired, and completely dependent to staff for all her activities of daily living. Resident was observed seated in her wheelchair, well-groomed in the dining room/activity room on 12/16/2018 at 12:00 PM and when approached and spoken to, smiled without answering. The comprehensive care plan (CCP ) dated 12/03/2018 identified advance directive as a care area. The CCP documented that the resident/family has been educated regarding advance directives. The targeted goal was that the advance directives were to be updated no less than every 3 months. The advanced directives are to be followed in accordance with the resident/ family member or designated representative's wishes as evidenced by discussion of MOLST (Medical Orders for Life Sustaining Treatments), DNI (Do Not Incubate), DNR (Do Not Resuscitate). The CCP also documented that advance directives would be reviewed by medical doctor and an ordered by a medical doctor. The CCP further documented that the advance directives would be maintained as part of the resident's medical records. The disciplines responsible for implementing this CCP were Social Work and Medical. Review of the interdisciplinary notes, specifically social service and physician notes revealed no documented evidence that facility staff discussed with the resident's family or designated representative issues concerning advance directives. There were no orders for advance directives in the resident's medical record. The most recent Social Service note documented in the resident's medical record was quarterly note dated 11/29/2018. The note did not provide documented evidence that the facility social worker discussed with, or provided written information to the family about advanced directives. The SSD (Social Services Director) was interviewed on 12 /17/2018 at 11:49 AM. The SSD stated that the advance directive discussion should be a part of the social services history portion of the resident's medical record. However, after reviewing the medical record the SSD determined that there was no documented evidenced that such issues had been discussed. On 12/18/2018 at 3:00 PM, the SSD stated to the State Surveyor that she contacted the resident's family member on 12/17/18. The family member stated that they would have a family discussion, a hard copy of the advance directive form and information packet was faxed to the family member. 415.3(e)(1)(ii)

Plan of Correction: ApprovedJanuary 8, 2019

1. The family of resident #122 was contacted by the Director of Social Services. Advance Directives was discussed with family member and written information was provided to the family. 12/19/2018
2. All residents will be reviewed to ensure that the Social Worker has discussed Advance Directives with resident or family (of cognitively impaired residents) and have provided written information of same. The resident?s attending physician/nurse practitioner will review and write an MD order as appropriate. 01/18/2019
3. The Director of Social Services reviewed the facility?s policy and procedure regarding Advance Directives and revised it as necessary to be in compliance with F578.
All Social Workers were inserviced by the Director of Social Services and Physicians/Nurse Practitioner inserviced by the Director of Inservice Education regarding continued compliance with F578 as it pertains to the discussion of Advance Directives and provision of same in writing. The inservice focused on the following:
a. Identification of the residents who are cognitively intact
b. On a quarterly basis, all residents will be reviewed as to the status of their advance directives and same will be discussed with the resident/family member to confirm current wishes.
c. The resident?s attending physician will be informed of the changes by the Social Worker/Nurse Manager
d. The attending physician/nurse practitioner will review and write orders as appropriate.
e. Any discrepancies should be reported to the Director of Social Services 01/25/2019
4. An audit tool was developed in order to monitor compliance with F578 as it pertains to the discussion of Advance Directives and provision of same in writing. The audit will be performed by the Director of Social Services as follows:
A ten percent sample of residents will be reviewed each month to ensure proper quarterly discussion (and provision in writing) of Advance Directives. The results will be reported at the Quality Assurance Meeting on (MONTH) 11, 2019. 02/11/2019 and ongoing.