The second component of a POC requires the facility to identify everyone who may be affected by the deficient practice and how the facility will ensure that the deficient practice does not occur to someone else. In simple terms, the survey team has usually looked at a sample of people. Let's say you have a six-bed facility and they look at three people. There are three other people who could have the same problem - even if surveyors only identified the problem for "One of three sampled individuals" this does not mean that individual number four might not have the same concerns or problems. All this means is that the survey team did not look at individual number four and he or she may have the same issues. To ensure that no individuals in the facility have the same issue or problem, the facility must identify how it is going to ensure the deficient practice does not affect others.
Thinking back to the last post, you will remember that the tag written was for failing to follow up on a physician's recommendation. The POC has set forth that the IDTeam will meet, make recommendations and the QIDP will implement those recommendations. The question at this point that must be considered is "Has the facility overlooked any other physician recommendations for anyone else residing in the facility?" To answer the question, the ICF must address how it is going to ensure that anyone potentially affected has been reviewed.
At this point the POC may state something like the following:
The QIDP will review physician recommendations for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations have been overlooked. In the event that a recommendations has been overlooked, the QIDP will refer the recommendation to the IDTeam for review and direction per the guardian, surrogate, or individual as appropriate.
Based on the above statement, the POC now clearly indicates that the QIDP will be responsible to check and ensure that there are no other individuals in the home being affected by the deficient practice. Further, if an individual is being affected, the the plan indicates how it will be corrected.
For the third part of this series we will look at what must be done to ensure that the problem does not occur again. This part is usually considered the "monitoring" to ensure the problem is caught or does not happen again section of the POC. For our purposes it is the third part of a POC.
