Lack of QAPI Documentation and Oversight Results in Repeat Deficiencies
Penalty
Summary
The facility failed to provide meeting minutes and evidence of sufficient governing oversight to demonstrate the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) Program for the last recertification survey of 2024. During an interview, the Administrator confirmed there was no documentation of QAPI activities addressing previous deficiencies in nutrition services and resident assessments. Review of the facility's QAPI policy indicated that the QAPI committee is responsible for helping departments and services implement systems to correct quality of care issues, but there was no documentation to show these responsibilities were fulfilled. This lack of documentation and oversight resulted in repeat deficiencies in resident assessments and food and nutrition services.