Recurring Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in the current survey ending January 9, 2025. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, improper timing and revision of care plans, and failure to provide quality care. Additionally, there were issues with the accountability of controlled medications, improper storage and labeling of medications, and inadequate food preparation and serving. These deficiencies were also noted in a previous survey ending February 29, 2024, indicating a lack of effective corrective action by the QAPI committee. The facility had previously developed plans of correction that included conducting audits and reporting results to the QAPI committee for review. However, the current survey revealed that these plans were not successfully implemented, as the same deficiencies persisted. The QAPI committee's failure to maintain compliance with regulations regarding assessments, care plans, medication management, and food services highlights ongoing issues in the facility's quality assurance processes.
Plan Of Correction
1. All areas identified during this annual survey have submitted plans of correction. All identified resident concerns that are correctable will be corrected. 2. Audits will be completed for all federal regulations identified as not in compliance to ensure any additional residents have been identified and corrective measures have been implemented. 3. All submitted plans of correction have specific education/re-educations listed for all appropriate disciplines that will be provided by the listed facility employees. The Executive Director will re-educate the QAPI committee of the expectations of the facility and role of the committee per federal regulation. 4. Audits for each citation will be submitted to the Quality Assurance Committee for review. The Executive Director or designee will audit the QAPI minutes monthly x3 to ensure all audits have been submitted and all identified areas have been addressed.