Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The survey ending January 17, 2025, identified repeated deficiencies related to maintaining a homelike environment, accuracy of assessments, updating/revising care plans, quality of care, and food service standards. These deficiencies were previously cited in a survey ending February 1, 2024, indicating a lack of effective implementation of corrective actions. The facility's plan of correction for maintaining a homelike environment included completing audits and reporting results to the QAPI committee. However, the current survey revealed that the QAPI committee failed to implement the plan successfully, resulting in ongoing non-compliance with regulations. Similarly, deficiencies in the accuracy of assessments and updating/revising residents' care plans were not addressed effectively, as the QAPI committee did not ensure compliance with the established corrective plans. Additionally, the facility's plans to address quality of care and food service issues, such as ensuring food was palatable and served at proper temperatures, were not successfully implemented. The QAPI committee's failure to ensure compliance with these plans resulted in repeated citations under various F-tags, including F584, F641, F657, F684, F804, and F812. This indicates a systemic issue in the facility's ability to sustain improvements and adhere to regulatory standards.
Plan Of Correction
The facility Quality Assurance Performance Improvement committee will continue to be held on a monthly basis and meet the expectations as outlined in the facilities policy. The Quality Assurance Performance Improvement committee has not been following the appropriate policy guidelines as outlined in the policy and therefore, the Administrator will provide re-education on the Quality Assurance Performance Improvement committee process and the expectations to active committee participants as outlined in the above-mentioned policy. The committee failed to successfully implement plan of corrections for previously identified areas by not reviewing audit findings and making any corrective recommendations. To assure compliance of the plan of correction, participating members (department heads) of the committee will present their specified areas at the committee meetings for discussion, committee recommendations, effectiveness and implementation of corrective actions. These presentations will include audit tools utilized to address areas of the plan of correction and will be reported on a monthly basis. Committee members will implement recommendations as discussed and detailed by the committee. Participating committee members will follow up on recommendations to assure continued compliance. Any outlying findings will be corrected and reported back to the committee for further discussion/recommendations. Monthly minutes from the Quality Assurance Performance Improvement committee will be forwarded to the Director of Clinical Operations for review and recommendations. Date of compliance 3/5/2025