Failure of QAA/QAPI Committees to Oversee Repeat Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to provide effective oversight of the plan of correction for deficiencies identified during the previous recertification survey. Specifically, the committees did not actively manage ongoing systemic issues related to medication error rates of five percent or more, food and nutrition services, and the antibiotic stewardship program. These areas had been identified as deficient in the prior survey, but were no longer considered high-focus topics by the QAA committee, despite their continued relevance. During interviews and record reviews, the Administrator confirmed that these systemic issues were not currently being addressed by the QAA committee, even though they had been included in the QAPI plan following the previous survey. The facility's policy and procedure for the QAPI plan outlines the need for ongoing data monitoring, performance measurement, and prioritization of problems, but these processes were not being followed for the repeat deficiencies. As a result, all 84 residents were affected by the lack of oversight and continued deficiencies in these critical areas.