Repeated Deficiencies in QAPI Implementation
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 multiple surveys. These deficiencies included a failure to prevent resident abuse and neglect, timely completion of comprehensive assessments, and inaccuracies in Minimum Data Set (MDS) assessments. Additionally, the facility struggled with developing comprehensive care plans and providing professional nursing services. The survey results also highlighted issues with ensuring a safe environment free of accident hazards, as well as failures in accountability for controlled medications and proper storage and labeling of medications. The facility was cited for not ensuring that physicians and certified registered nurse practitioners wrote, signed, and dated progress notes with each visit. Furthermore, the facility's infection control practices were found to be deficient. Despite the facility's plans of correction, which included completing audits and reporting results to the QAPI committee, the committee was ineffective in addressing and correcting these deficiencies. The repeated nature of these issues across multiple surveys indicates a systemic problem in the facility's ability to implement and sustain effective quality assurance measures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility is unable to fix the Quality Assurance audits at the time of the survey. There were no other issues identified at the time of the survey. To prevent a future occurrence, the Nursing Home Administrator will educate department heads on the Quality Assurance and Process Improvement Policy. To monitor and maintain ongoing compliance, the Nursing Home Administrator/designee will complete an audit weekly x4 then monthly x2 to ensure that audits are being completed, reviewed and have process improvement plans put into place if necessary. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.