Reeves Foundation - Irvine

Based on documentation review and interview, the administrator failed to designate, in writing, individuals who were present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator was not present on the nursing supported group home's premises. Findings include: 1. The Compliance Officers requested to review a written designation by the Administrator of all individuals who would be present on the premises when the Administrator was not present, however, a designation was not provided for review. 2. In an interview, E1 reported they have shift leads although do not have a designee in writing. E1 acknowledged the administrator had not designated, in writing, all individuals who would be present at the nursing supported group home and accountable for the facility when the administrator was not present.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's medical record revealed documentation of a chest x-ray completed as R2's freedom from infectious tuberculosis. However, no record of a Tuberculin skin test or a blood test conducted per current CDC recommendation was available for review. 3. In an interview, E1 reported thinking chest x-rays met current requirement. E1 acknowledged R2's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on documentation review and interview, the Administrator failed to ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed policies covering medication administration, storage, disposal, and documentation. However, the policies were not reviewed and signed by a pharmacist. 2. In an interview, E1 acknowledged the provided medication administration policies and procedures did not include documentation of review and approval by a pharmacist.