Deficiency in QAPI and QAA Documentation and Monitoring
Penalty
Summary
The facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI) and Quality Assurance and Assessment (QAA) activities, which could impact the quality of care and life for all residents. During an interview, the Director of Nursing (DON) mentioned that a Performance Improvement Plan (PIP) for Pre-Admission Screening and Resident Review (PASARR) was initiated approximately one month prior, but only about 25% of the PASARRs had been reviewed or redone. The Regional Director of Clinical Services was unable to locate any records for the PIPs, indicating a lack of organization and documentation. The Nursing Home Administrator (NHA), who had been in her position since January, conducted QAPI meetings and initiated a PIP for environmental concerns and maintenance repairs. However, she was unable to locate records for clinical PIPs and could not account for activities before her tenure. The Quality Assurance Meeting minutes from January showed no QAA Committee recommendations, and the facility's guidelines emphasized the need for maintaining documentation and demonstrating evidence of ongoing QAPI activities. The absence of records and documentation for clinical PIPs highlights a deficiency in the facility's ability to systematically identify, report, investigate, analyze, and prevent adverse events, as required by their standards.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On QAPI meeting was held to complete a system review and new identified PIP were initiated. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. No residents were found to be directly affected by this practice. A review of current PIPs was completed on to assess the need for modifications or updates. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Administrator/designee to complete PIP education with department managers to reinforce adherence to identifying trends and concerns proactively. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Administrator/designee to conduct a weekly review of PIP tracking tools to ensure ongoing compliance is met ensure compliance with federal regulation F865 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.