QAA Committee Failed to Address Survey-Identified Deficiencies in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) did not identify or include in its Quality Assurance Performance Improvement (QAPI) plan the deficient trends found by surveyors during the recertification survey, specifically regarding call light response times and the lack of a homelike environment for residents. During an interview and review of the QAPI program, administrators and the DON confirmed that the QAPI team was primarily monitoring falls, pressure ulcer reduction, weights, and urinary tract infection prevention, but not the issues of call light response or homelike environment. The DON acknowledged that call light response was an ongoing project but was unable to identify a root cause for the issue, stating that it was challenging to do so. Additionally, although there was a budget approved for improvements to residents' rooms to address the lack of a homelike environment, this initiative was not discussed in the QAA Committee nor included in the QAPI plan. The facility's policy on QAPI indicated that the purpose of the plan is to continually assess performance in all service areas to achieve person-centered care, but the identified deficiencies were not incorporated into the facility's ongoing quality improvement processes.