Repeat Deficiency in Reporting Abuse Allegations
Penalty
Summary
The facility failed to implement its policies effectively, particularly in monitoring and tracking performance in previously identified areas of concern. During a complaint survey conducted in December 2024, the facility was cited for F609 due to issues related to the reporting of abuse allegations. In the current survey, the same citation was identified again, indicating a lack of sufficient auditing and oversight to address the previous deficiency. The Administrator admitted to not reviewing the actual grievance forms, only the grievance log presented at the monthly Quality Assurance and Performance Improvement (QAPI) meetings. The facility's policies, including the Complaint/Grievance policy and the Abuse, Neglect, Exploitation & Misappropriation policy, require that grievances and allegations of abuse be reviewed during QAPI meetings. However, the Administrator, who was not in position during the December 2024 survey, could not confirm what actions were taken to prevent repeat deficiencies. The facility's Quality Assurance Performance Improvement Program policy emphasizes the importance of focusing on care outcomes and quality of life, yet the failure to adequately monitor and address previous deficiencies suggests a gap in the implementation of these policies.
Plan Of Correction
1) On QAPI was reviewed by the Regional Vice President of Operations and Regional Director of Clinical Services for the months of and audits were reviewed and updated. (2) A comprehensive review of QAPI plans were conducted by the RVPO and RDCS to ensure all actions and supporting audits were completed and ongoing audits up to date. Any areas of concern were corrected at this time. (3) 1. Education provided by RDCS to the Interdisciplinary team on the importance of QAPI and how to ensure efficient outcomes through monitoring and evaluation according to facility QAPI policy; as well as a comprehensive review of the facility's Quality Assurance Performance Improvement program policy. 2. Education provided by the Executive Director to the IDT on how the facility will monitor the effectiveness of the performance improvement plan related to quality assurance and process improvement. 3. All grievances (grievance forms and log) will be reviewed by ED, SSD and DON daily 5 days a week. 4. Quality reviews will be conducted weekly for performance improvement adherence; if indicated, an Adhoc QAPI will be completed and submitted to monthly QAPI with any findings. (4) A quality review will be completed by the Executive Director or designee of grievances to ensure the policy and process is adhered to, along with a quality review of performance improvement audits each 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.