QAPI Committee Failed to Identify and Address Infection Control and Social Services Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify ongoing issues and did not develop or implement corrective action plans for deficiencies in Infection Prevention and Control practices and Social Services. Review of QAPI meeting minutes revealed that meetings were focused on reviewing new resident assessments, but did not address or identify the specific deficiencies related to resident assessment and care planning. The Administrator confirmed that these issues were not discussed in recent QAPI meetings, and that the facility had not recognized the assessment deficiencies identified by the survey team. Additionally, the Social Services Director was found to be incompetent in job duties and was terminated, with the Director of Nursing assuming those responsibilities. Despite this change, the facility's admission records were only reviewed weekly, and the Administrator asserted full compliance. The facility's policy required an ongoing, data-driven QAPI program focused on care outcomes and quality of life, but the observed practices did not align with these requirements, resulting in unaddressed deficiencies that placed all residents at risk.