Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a survey ending January 15, 2025. These deficiencies included unresolved grievances, outdated care plans, non-compliance with physician's orders, lack of nurse aide performance reviews, and failure to honor residents' food and drink preferences. The facility had previously developed plans of correction for these issues following a survey ending February 23, 2024, which included audits and reporting to the QAPI committee. However, the current survey revealed that these corrective measures were ineffective. The specific deficiencies cited in the current survey were under F585 for unresolved grievances, F657 for care plan updates, F684 for following physician's orders, F730 for nurse aide performance reviews, and F807 for honoring food and drink preferences. Despite the facility's efforts to address these issues through their QAPI committee, the repeated nature of these deficiencies indicates a failure to effectively implement and sustain corrective actions. The report highlights the facility's ongoing struggle to address and rectify these recurring issues, as evidenced by the ineffective performance of the QAPI committee in ensuring compliance with nursing home regulations.
Plan Of Correction
1. Previous leaderships have failed to comply with the regulation deficiency of 867. Current Nursing Home Administrator will monitor the scope of practice 867. 2. The Executive Director or designee will ensure that grievances were resolved, care plans were revised/updated, quality of care that physician's orders were followed, nurse aide's performance reviews were conducted, and food and drink preferences were honored. 3. The Director of Nursing (DON)/designee reeducated the licensed staff on the facility's care plan policy. The DON/designee reeducated the licensed nursing staff of the quality of care that physician's orders were followed. The DON/designee will ensure that the nurse aide performance's reviews were conducted. Executive Director (ED) reeducated the Human Resources Coordinator (HRC) and the Director of Nursing on the facility's employee job performance evaluation policy. The Human Resources Coordinator will notify the Director of Nursing of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner. 4. The Executive Director reeducated the department managers on the facility's Quality Improvement Performance Improvement (QAPI) policy and on the elements of QAPI. 5. The Director of Nursing/designee to conduct Quality Improvement monitoring of regulation F657 in correcting deficient practices related to revising/updating care plans. Audits will be completed of care plans on residents with pressure ulcers for goal dates to review and update care plan weekly X 8 weeks. The DON/designee to conduct Quality Improvement of regulation F684 in correcting deficient practices related to quality of care, following physician's orders. Audits of 5 residents receiving blood sugar checks for documentation of notifications per physician orders 5X per week X 2 weeks, weekly X 4. The HRC/Designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 730 to ensure nurse aide performance evaluations were completed annually based on hire date. QI monitoring conducted via nurse aide personnel file review weekly for 8 weeks. 6. Findings to be reported to the QAPI committee meeting and updated as indicated. Quality Improvement schedule modified based on findings.