Failure to Sustain Ongoing Compliance with QAPI for Repeat Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance regarding previously cited deficiencies. Specifically, the facility was cited for repeat deficiencies in quality of care, development and implementation of comprehensive care plans, and self-administration of medications (SAM). These deficiencies were identified during the current survey and had also been cited in a previous survey. For quality of care, the facility did not follow current physician orders and parameters for two residents reviewed for medications. In the area of care planning, the facility did not develop or maintain a care plan to ensure appropriate care for a resident with increased care needs due to decline. Regarding SAM, the facility failed to complete a self-administration of medications assessment for a resident observed with medications at bedside. Review of QAPI meeting minutes over several months showed a lack of ongoing data and tracking related to these repeat citations. The administrator confirmed that the facility had not been monitoring previous compliance with surveys and only recently began to form a plan to address and maintain compliance. The facility's QAPI policy required the development, implementation, and evaluation of corrective actions or performance improvement activities, but this was not demonstrated in practice for the cited areas.