THE OASIS AT FELLOWSHIP SQUARE SURPRISE

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of six residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident.

Findings include:

1. A review of R5's medical record revealed a service plan, dated in January of 2024 for directed care services. However, a service plan after January 2024 was not available for review.

2. In an interview, E1 and E4 reported the service plan was reviewed and updated. However, the service plan was not available for the department to review at the time of inspection.

3. In an interview, E1 acknowledged R5 received directed care services and the current service plan was not available for the department to review at the time of inspection.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from a nurse or medical practitioner, for three of seven residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements.

Findings include:

1. Review of R4's medical record revealed written service plans dated October 2023 and January of 2024. The service plans indicated R4 received medication administration; however, these service plans were not signed and dated by a nurse or medical practitioner.

2. Review of R6's medical record revealed written service plan dated March of 2024. The service plans indicated R6 received medication administration; however, the service plan was not signed and dated by a nurse or medical practitioner.

3. Review of R7's medical record revealed a written service plan dated March of 2024. The service plan indicated R7 received medication administration; however, this service plan was not signed and dated by a nurse or medical practitioner.`

4. In an interview, E1 acknowledged R4's, R6's, and R7's service plans did not include a signature and date from a nurse or medical practitioner.

Based on observation, documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:

1. During the environmental tour, the Compliance Officer observed the facility provided medication administration services.

2. A review of facility documentation revealed a policy titled, "Medication Policies and Procedures." However the medication services policy and procedure was not reviewed by a medical practitioner, registered nurse, or pharmacist, signed and dated.

3. In an interview, E2 acknowledged the medication services policy and procedure was not reviewed by a medical practitioner, registered nurse, or pharmacist, signed and dated.