Failure to Maintain Effective QAPI Program for Resident Safety Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by its lack of identification and follow-up on critical areas requiring improvement. During the survey, an Immediate Jeopardy concern was identified regarding hot water temperatures, which the facility was unaware of. Additionally, there was a concern about the accommodation of resident needs related to call light accessibility. Resident council meeting minutes documented a complaint about the absence of hot water in resident rooms, to which the facility responded by stating they would check hot water temperatures weekly. However, QAPI meeting minutes showed no further discussion or documentation of weekly hot water temperature checks, nor were any logs available. In an interview, the administrator could not confirm whether a QAPI meeting had been held for the previous month and was unaware of any QAPI discussions or performance improvement plans addressing water temperature issues or call light accessibility.
Plan Of Correction
F865 – QAPI Program/Plan, Disclosure/Good Faith Attempt Element #1: The facility’s QAPI plan was updated on 5/27/2025 to include specific goals and performance indicators. The QAPI committee was re-structured to ensure monthly meetings with effective data analysis and prioritization of performance improvement projects. Element #2: The Administrator initiated a QAPI participation review to ensure all department heads are submitting routine data and quality indicators for review and action planning. Element #3: The Administrator reviewed the policy on Quality Assurance Performance Improvement and revised as necessary. Community staff were provided education on QAPI. Element #4: The Administrator and/or designee will audit QAPI meeting minutes for 3 months to ensure compliance with active, data-driven performance improvement projects. QAPI effectiveness will also be evaluated monthly by ownership. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025