Deficiency Records for Alternative Healthcare Solutions LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Alternative Healthcare Solutions LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-02 | 2023-06-12 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-05-02 | 2023-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-02 | 2023-05-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-02 | 2023-05-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-02 | 2023-05-18 | N |
| Post nurse staffing information every day. | Health | 2023-05-02 | 2023-05-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-02 | 2023-05-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-02 | 2023-05-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-02 | 2023-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-02 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-02 | 2023-05-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-02 | 2023-05-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-02 | 2023-05-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-02 | 2023-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-02 | 2023-05-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-02 | 2023-05-05 | N |
| Provide enough space and equipment to meet each resident's needs | Health | 2022-01-27 | 2022-03-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-27 | 2022-03-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-27 | 2022-03-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-01-27 | 2022-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-15 | 2022-02-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-27 | 2022-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-27 | 2022-02-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-02-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-27 | 2022-02-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-27 | 2022-02-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-01-27 | 2022-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-02-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-01-27 | 2022-02-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-27 | 2022-02-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-01-27 | 2022-02-15 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2022-01-27 | 2022-01-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-15 | 2022-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-15 | 2022-01-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-12-15 | 2022-01-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-12-15 | 2022-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-15 | 2022-01-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-15 | 2022-01-19 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2021-12-15 | 2022-01-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-15 | 2022-01-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-15 | 2022-01-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-15 | 2021-12-15 | N |
