Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys throughout 2024. These deficiencies included failure to provide notice of bed hold policy, timely completion of comprehensive assessments, development of resident care plans, and provision of activities of daily living care to dependent residents. Additionally, the facility was cited for inadequate quality of care, improper feeding tube management, failure to maintain accurate accounts of controlled medications, improper labeling and storage of drugs and biologicals, and failure to prepare and follow menus to meet residents' needs. Despite developing plans of correction that included audits and reporting results to the QAPI committee, the facility consistently failed to maintain compliance with regulations. The repeated citations under various F-tags, such as F625, F636, F656, F677, F684, F693, F755, and F803, indicate that the QAPI committee's efforts were ineffective in ensuring ongoing compliance with nursing home regulations. The deficiencies were identified in surveys conducted on several dates, including January 18, February 23, June 19, September 19, and October 21, 2024, with the most recent survey ending on December 12, 2024.
Plan Of Correction
The center recognizes the need for the implementation of and the maintenance of effective Quality Assessment and Assurance/ Quality Assurance and Process Improvement activities to sustain system compliance. Current residents and new admissions have the potential to be affected. The facility Quality Assurance and Process Improvement committee will conduct a root cause analysis to determine steps to implement and sustain systemic correction as it relates to the cited deficiencies. To prevent recurrence, the Nursing Home Administrator and Director of Nursing will be reeducated on the policy for Quality Assessment and Assurance/Quality Assurance and Process Improvement including sustaining systemic correction by the Regional Director of Clinical Services or designee. To monitor and maintain compliance, the facility Quality Assurance and Process Improvement committee will conduct a weekly review of plan of correction audits and make recommendations as needed.