Failure of QAA Committee to Identify and Resolve Systemic Problems
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee effectively identified and resolved systemic problems, impacting all 20 residents in the facility. Document review and staff interviews revealed that while the QAPI plan required comprehensive monitoring, evaluation, and cross-departmental involvement, the committee did not have a method to measure or track improvements in performance improvement plans (PIPs). The Director of Nursing (DON) was unable to provide evidence of improved outcomes or measurements for the PIPs, instead relying on incident counts from the prior month without a system to track progress. This deficiency resulted in failures to report resident assessments and comprehensive care planning, as required, with the potential for adverse outcomes when residents' needs were not identified.