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 repeated issues identified in multiple surveys. The deficiencies were related to timely quarterly Minimum Data Set (MDS) assessments, accurate MDS assessments, comprehensive care plans, and overall quality of care. Despite developing plans of correction that included quality assurance systems, the facility did not maintain compliance with the cited nursing home regulations. The facility's plan of correction for the deficiency regarding quarterly assessments, cited in previous surveys, involved completing audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee did not successfully implement their plan to ensure ongoing compliance with regulations regarding quarterly assessments. This failure was cited under F638. Similarly, the facility's plan of correction for deficiencies related to accurate resident assessments, comprehensive resident care plans, and quality of care also involved audits and QAPI committee reviews. Yet, the current survey found that the QAPI committee failed to implement these plans effectively, resulting in ongoing non-compliance with regulations. These failures were cited under F641, F656, and F684, respectively.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to correct systems in the facility. 3. Re-evaluation of the Quality Assurance process has resulted in a reorganization of the current Performance Improvement Plans. Regular quarterly meeting in February finalized new Performance Improvement Plans to be monitored and reevaluated in 3 months. 4. Administrator to monitor for compliance.