From 1/4/16 to 1/13/16 six Quality Management Program surveys were completed.
Three of the six surveys were conducted in large facilities, and the remaining surveys were conducted in small facilities.
• The three small facilities did not have a QMP.
• One large facility had a QMP; however, there was deficient practice found in the areas of medication administration. The QMP documented medication administration activities; however, the QMP activities did not resolve problems, as evidenced by current deficient practice.
• A second large facility had a QMP; however, it did not contain all of the required elements and there was no documentation provided regarding the QMP activities.
• A third large facility had a QMP; however, current deficient practice was found and it was later determined the facility failed to conduct QMP activities, as disclosed in the plan.
CHCA In-Focus - January 28, 2016