Lack of QAPI Documentation for Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes or evidence of Quality Assurance and Performance Improvement (QAPI) program efforts to address three repeat deficiencies in Resident Rights, Laboratory Services, and Pharmacy Services. These deficiencies were previously identified during a recertification survey conducted by the California Department of Public Health (CDPH) in 2024. During an interview, the Administrator acknowledged the absence of documentation and emphasized the importance of discussing and developing a QAPI program to address these deficiencies. The lack of documentation indicated that the facility did not effectively investigate, analyze, or implement corrective actions to improve performance in these areas. A review of the facility's undated policy and procedure (P&P) titled QAPI Plan revealed that the QAPI Steering committee is responsible for analyzing performance and identifying areas for improvement. The P&P also stated that meeting minutes should be recorded and shared with the QAPI Steering committee, executive leadership, and staff. However, the facility did not adhere to these guidelines, as evidenced by the absence of meeting minutes or any documentation of QAPI activities related to the identified deficiencies. This lack of documentation and follow-up placed residents at risk for harm if the areas identified were not adequately addressed.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/24/25, the Quality Assurance (QA) Nurse reviewed the facility's "Statement of Deficiencies (SOD)," dated 3/8/2024, related to Resident Rights, Laboratory Services, and Pharmacy Services. On 3/24/25, the QA Nurse developed a Quality Assurance and Performance Improvement (QAPI) plan for the current deficiencies. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the facility's Statement of Deficiencies, dated 3/8/24, to ensure each deficient practice noted had a QAPI developed with a root cause, interventions, goals, and how the facility would monitor and audit the program. There was 1 deficiency without a developed QAPI plan. On 3/24/25, the Administrator and QA Nurse developed a QAPI from the facility's previous deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Administrator in-serviced the QA Nurse on the facility's policy and procedure, titled "QAPI Plan," with emphasis on the QAPI Steering committee analyzing performance to identify and follow up on areas of opportunity, with meeting minutes being recorded and shared with the QAPI Steering committee, executive leadership, and staff. The in-service emphasized the facility continually identifying opportunities for improvement and using the criteria to prioritize opportunities such as aspects of care affecting large numbers of residents, regulatory requirements, SOD from complaint visits, and surveys. The in-service also included ensuring the facility's QAPI plans include a root cause, interventions, goals, and how the facility would monitor and audit the program. The Administrator will conduct monthly and as-needed (PRN) audits on the facility's QAPI plans to ensure facility-identified problems or deficient practices on a Statement of Deficiencies are QAPI and maintained. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility developing a Quality Assurance and Performance Improvement plan for deficient practices for three months or until compliance is met.