Failure to Implement and Document QAPI Program Activities
Penalty
Summary
The facility failed to develop and implement action plans to correct identified quality deficiencies, as well as to measure the success of actions taken and track performance to ensure improvements were realized and sustained. The facility also did not track medical errors and adverse events, analyze their causes, or implement preventive actions and mechanisms. Additionally, the facility did not conduct at least one Performance Improvement Plan (PIP) annually that focused on high-risk or problem-prone areas, as required by their own policies and federal regulations. Record review revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program policy required the establishment of a Quality Assessment and Assurance (QAA) Committee, regular meetings, data collection and analysis, and the development and implementation of corrective action plans. The policy also required the QAA Committee to regularly review and analyze data, including data from drug regimen reviews, and to act on this data to make improvements. However, there was no documentation available to demonstrate that these activities were being carried out as required. During an interview, the Nursing Home Administrator stated that the QAPI/QAA program met at least once a month and included the DON, Medical Director, and other interdisciplinary team members. Despite this, the Administrator was unable to provide signature pages or any other documentation related to the meetings, as the QAPI/QAA book was missing and its whereabouts were unknown. This lack of documentation meant there was no evidence to support that the facility was following its own QAPI policies or federal requirements regarding quality assurance and performance improvement activities.