Failure to Monitor Effectiveness of QAPI Plan of Correction
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) committee implemented and monitored the effectiveness of its plan of correction for previously cited deficiencies at F695, F761, F842, and F880. According to the facility's QAPI Program, the committee is responsible for developing monitoring tools, creating plans of correction, and evaluating the effectiveness of corrective actions. The plan of correction submitted after the last recertification survey outlined specific responsibilities for the DON, SSD, and IP or their designees to review compliance data and bring results to monthly QAPI meetings for a set period. During an interview and document review with the Administrator and DON, it was found that there was no documentation to show that the QAPI committee had monitored the effectiveness of the corrective actions for the cited deficiencies. This lack of documentation indicated that the committee did not follow through with the required monitoring and evaluation processes as outlined in their own policies and the submitted plan of correction.