F868 in Delaware. Pick another state for the same tag.
Against expectation — 2023
Delaware cites F868 more often than its own record predicts
Versus expected share6.20×
6.20 times the share F868 takes of citations nationally.
Share of Delaware citations1.59%
Of every deficiency written in Delaware in 2023, this is the portion that was F868.
Delaware1.59%
National0.26%
Share of all citations that were F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F868 findings written in Delaware, 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.
E · No harm, potential for more than minimal, patternSeptember 25, 2023
Based on a review of facility documentation, it was determined that the facility failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and to maintain a QAPI committee of the required members. Findings include:
8/30/23 - A review of the facility QAPI meeting minutes for the last seven quarters revealed:
Two meetings have taken place in the last seven quarters. There were no QAPI Meetings held in 2022.
- Q4 2021 QAPI Meeting - The Medical Director was not present.
- Q1 2023 QAPI Meeting - The Director of Nursing, the Medical Director and the Infection Preventionist were not present.
9/8/23 at 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction