Recurring Deficiencies in Quality of Care and Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of the current survey ending December 19, 2024. The survey identified repeated deficiencies in areas such as quality of care, specifically in following physician's orders, treatment of pressure ulcers, medication storage and labeling, and infection control practices. These deficiencies were previously cited in a survey ending January 11, 2024, and the facility had developed plans of correction that included audits and reporting to the QAPI committee. However, the current survey revealed that these plans were not successfully implemented, leading to ongoing non-compliance. The specific deficiencies included failure to follow physician's orders, inadequate treatment of pressure ulcers, improper storage and labeling of medications, and non-compliance with infection control practices. Despite the facility's plans to conduct audits and review results with the QAPI committee, these measures were ineffective in maintaining compliance with the relevant regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Plan Of Correction
1. The Quality Assurance and Performance Improvement committee reviewed current survey deficiencies and plan of correction including audits. 2. The Quality Assurance and Performance Improvement committee reviewed previous survey/complaint deficiencies to correct deficiencies and ensure that plans to effectively address recurring deficiencies. 3. The Quality Assurance and Performance Improvement committee was educated on the Quality Assurance and Performance Improvement Plan. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.