QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of a survey ending January 24, 2025. The survey identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records. These deficiencies were previously cited in a survey ending January 4, 2024, where the facility had developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. Specifically, the facility's plan of correction for a deficiency regarding the failure to update residents' care plans included completing audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee did not successfully implement this plan, as evidenced by the citation under F657. Similarly, the plan of correction for deficiencies in pharmacy procedures, services, and records involved audits and QAPI committee reviews, but the current survey, cited under F755, showed that these measures were not effectively implemented.
Plan Of Correction
No specific residents and/or staff were affected by these deficiencies. Currently, the core team of the Quality Assurance and Performance Improvement committee meets weekly and will work with a consultant to ensure focus on reoccurring issues. The Nursing Home Administrator and/or designee will retrain the members of the Quality Assurance and Improvement Committee on its responsibility for maintaining compliance with previously cited deficiencies. The Nursing Home Administrator and/or designee will audit open plan of corrections weekly x 4 then monthly x 2 or until substantial compliance is accomplished. Findings will be reviewed at the monthly facility Quality Assurance and Performance Improvement meeting.