Failure to Implement and Document Effective QAPI Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to implement and ensure effective oversight of the Quality Assurance and Performance Improvement (QAPI) plan. The Administrator (ADM) reported that while QAPI meetings were held monthly, there was no documentation of these meetings prior to March. Issues regarding call light response times were identified at the end of February, and these issues persisted into March, as noted during resident council meetings. However, a QAPI initiative addressing call light response times was not implemented until March, despite the presence of ongoing trends. The ADM acknowledged that earlier intervention through QAPI could have been beneficial but was delayed due to reliance on the previous Director of Nursing's (DON) opinions. Further review revealed that there was no QAPI activity documented for April, even though the call light response issue remained unresolved. The ADM stated that no complaints about call lights were raised during the resident council meeting in April, and attempts to locate previous QAPI documentation in the DON's office were unsuccessful. The ADM recognized that failure to implement QAPI in a timely manner could allow negative trends to continue, increasing risks to residents and failing to enhance care. The QAPI process was described as ongoing and monitored daily, with new issues added as trends were identified, but the lack of documentation and timely action was evident. The facility's policies and procedures outlined a comprehensive QAPI program, including regular data tracking, performance measurement, root cause analysis, and corrective action monitoring. The QAPI committee was responsible for overseeing these activities, meeting monthly to review reports and make necessary adjustments. However, the lack of documentation, delayed initiation of QAPI projects, and incomplete follow-through on identified issues demonstrated a failure to adhere to these established policies and procedures, resulting in the cited deficiency.
Plan Of Correction
F-tag 867 I: Corrective Action for residents found to have been affected: • On May 2025, four QAPI's were initiated: - Wound Management (05/06/2025) - Informed Consents for initiation and renewal of Psychotropic Drugs (05/06/2025) - Risk Management Process (05/06/2025) - Pharmacy Recommendation Compliance (05/13/2025) II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • QAPI's were initiated based on the identified issues will be presented during the monthly QA meeting. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • An in-service education were provided by the Assistant Regional Director of Clinical Services (ARDCS) to the Administrator and Department Members on 6/09/2025 regarding the QAPI/QAA Activities, roles and responsibilities of each member of the QAPI/QAA Committee members to ensure a system and processes are in place for reporting/identifying problems in the facility, establishing corrective actions by the committee, establishing methodology for analysis of the action plans, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and the committee members' responsibilities in reporting findings to the administrator and the governing body. • The Administrator/designee shall initiate posted information monthly to the residents and staff regarding projects that the QAPI committee is working on, including the progress of each project. IV: Facility's plan to monitor corrective actions, achieve & sustain compliance, and integrate the POC to QA Process: • The Assistant Regional Director of Clinical Services (ARDCS) will review the quarterly activities of the QAPI program that is discussed in the quarterly QA Committee and posted in the facility. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025