Deficiency in QAPI Documentation and Monitoring
Penalty
Summary
The facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI) activities, which could impact the quality of care and life for all residents. During an interview, the Director of Nursing (DON) and the Regional Director of Clinical Services revealed 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 admitted to being unable to locate any records for the PIPs, stating that they were not on record and not organized. The Nursing Home Administrator (NHA) confirmed that QAPI meetings had been conducted, but was unable to locate any records for clinical PIPs, aside from environmental and maintenance plans. The NHA acknowledged that there were no records for clinical PIPs and emphasized the importance of QAPI in monitoring, analyzing, and correcting problems to ensure residents receive necessary care and services. A review of the Quality Assurance Meeting minutes showed no QAA Committee recommendations, and the facility's guidelines required maintaining documentation and demonstrating evidence of an ongoing QAPI program. However, the facility failed to present such documentation, indicating a widespread deficiency in their quality assurance processes.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On PASSR resubmitted for resident # 62. No other deficient practice noted. 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. On a full house audit was completed for PASSR's needing resubmission due to new diagnosis. No other deficient practice noted. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The DON/designee conducted education with social services and DON on ensuring request for new submission of PASSR is completed with new diagnosis meeting criteria, with an emphasis on the components of Federal regulation F644. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The DON/Designee will conduct an audit of residents with new diagnosis meeting criteria for resubmission of PASSR to ensure compliance with N906 weekly X 4 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 a time substantial compliance has been determined.