Sacred Heart Homes, Inc..

“Based on the documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.   Findings include:   1. A review of the facility's policies and procedures revealed no documentation indicating that the policies and procedures were reviewed and updated as needed.   2. In an interview, E2 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.”

“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 that the facility provided medication administration services.   2. A review of facility policies and procedures revealed a policy titled "Medication Policy and Procedure.” However, the medication policy and procedure were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist.   3. In an interview, E2 acknowledged that the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist”

“Based on the documentation review and interview, the manager failed to ensure that a pest control program that complied with A.A.C. R3-8-201(C)(4) was implemented and documented. Findings include: 1 . During an inspection, the Compliance Officer requested to review the facility's pest control program. However, documentation of the program was not available for review during the inspection. 2 . In an interview, E2 acknowledged the facility had no pest control program that complies with A.A.C. R3-8-20l(C)(4) implemented and documented.”