QAPI Committee Fails to Address Recurring Deficiencies
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 current survey identified repeated deficiencies related to the development and implementation of comprehensive care plans, updating and revising care plans, providing quality of care, maintaining a safe environment free of accident hazards, and ensuring proper storage and labeling of medications. Additionally, the facility failed to maintain compliance with regulations regarding the accurate accounting of controlled medications and ensuring food was palatable and served at the proper temperature. The facility's plans of correction for deficiencies cited during the previous survey ending February 29, 2024, included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee failed to successfully implement these plans to ensure ongoing compliance with the regulations. Specifically, deficiencies were noted under F656 for comprehensive care plans, F657 for updating/revising care plans, F684 for quality of care, F689 for a safe environment, F755 for pharmacy services, F761 for medication storage and labeling, and F804 for food palatability and temperature. The repeated deficiencies indicate that the facility's QAPI committee was ineffective in maintaining compliance with the cited regulations. Despite having plans of correction in place, the facility did not achieve the necessary improvements, as evidenced by the recurrence of the same issues in the current survey. The lack of effective implementation and monitoring of corrective actions contributed to the ongoing non-compliance with the required standards.
Plan Of Correction
The center will continue to meet related to Quality Assurance Performance Improvement (QAPI) and if a plan is ineffective after reviewing, the plan will be revised and with further auditing and surveillance initiated. Residents affected by previous deficiencies have the potential to be affected. The administrator will provide education to the quality assurance performance improvement committee on the committee's role in improvement activities regarding federal regulations. Monitoring will be captured through auditing quality assurance performance improvement minutes monthly for 3 months. The audits will be conducted by the Administrator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.