Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F837 in Louisiana. Pick another state for the same tag.
Against expectation — 2024
Louisiana cites F837 less often than its own record predicts
Versus expected share0.47×
0.47 times the national share — cited less often here than elsewhere.
Share of Louisiana citations0.04%
Of every deficiency written in Louisiana in 2024, this is the portion that was F837.
Louisiana0.04%
National0.09%
Share of all citations that were F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Louisiana surveyors wrote
F837 findings written in Louisiana, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
L · Immediate jeopardy, widespreadJanuary 16, 2019
Based on interviews and record review, the facility failed to ensure the governing body established and implemented policies/procedures regarding the management and operation of the facility. This deficient practice was evidenced by the facility's failure to have policies and procedures to address how 6 (S10LPNTx, S15CNA, S17CNA, S21CNA, S22CNA, S23CNA) of 14 (S5QA, S6LPN, S7LPN, S10LPNTx, S13CNASup, S14CNA, S15CNA, S16CNA, S17CNA, S18CNA, S21CNA, S22CNA, S23CNA, S25CNA) direct care staff would readily identify the code status of all residents in the facility, and/or the appropriate actions direct care staff should implement in the event a resident was found unresponsive. …
F · No harm, potential for more than minimal, widespreadJune 10, 2024
Based on interviews and record review, the facility failed to ensure the administrator reported to and was accountable to the governing body. S1ADM failed to ensure the facility's QAPI program was maintained.
This deficient practice had the potential to affect a census of 87 residents.
Findings:
A review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI), as of 06/10/2024, revealed, in part, the following:
11. Governance and leadership:
a. The governing body and/or executive leadership is responsible and accountable for the QAPI program.
b. Governing oversight responsibilities include, but are not limited to the following:
ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities.
iii. …
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