F865 in Puerto Rico. Pick another state for the same tag.
Against expectation — 2024
Puerto Rico cites F865 more often than its own record predicts
Versus expected share1.90×
1.90 times the share F865 takes of citations nationally.
Share of Puerto Rico citations0.35%
Of every deficiency written in Puerto Rico in 2024, this is the portion that was F865.
Puerto Rico0.35%
National0.19%
Share of all citations that were F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Puerto Rico surveyors wrote
F865 findings written in Puerto Rico, 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.
F · No harm, potential for more than minimal, widespreadApril 9, 2024
Based on observations, review of policies procedures, review of facility documents and facility staff interview performed on 04/7/2024 through 04/09/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to maintain a Quality Assurance and Performance Improvement Program (QAPI). Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality. …
C · No harm, potential for minimal, widespreadMay 23, 2019
Based on a recertification survey, review of QAPI program activities and interview with hospital pharmacist (employee #8) and facility director (employee #2) performed from 05/21/19 thru 05/23 /19, from 8:00 am thru 4:30 pm, it was determined that the facility failed to ensure that Quality Assurance and Performance Improvement QAPI program plan include relevant information of QAPI/QAA activities, related with medication use and the appropriateness of pharmacy services.
Findings include:
1. …
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