Repeated QAPI Failures Lead to Ongoing Regulatory Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations by not effectively addressing recurring deficiencies identified in multiple state surveys. Despite developing plans of correction that included quality assurance systems such as audits and QAPI committee reviews, the facility continued to have repeated deficiencies in several key areas. These areas included care plan revisions, provision of quality care, ensuring a safe environment free from accident hazards, maintenance of intravenous catheters, and accountability for controlled medications. Specifically, the facility's plans of correction for deficiencies related to care plan timing and revision, quality of care, accident hazards, intravenous catheter maintenance, and controlled medication accountability all involved conducting audits and reporting results to the QAPI committee. However, subsequent surveys found that these measures were not successfully implemented or sustained, as evidenced by repeated citations under F657, F684, F689, F694, and F755. The QAPI committee was found to be ineffective in ensuring ongoing compliance with regulations in these areas. The report does not provide specific details about individual residents or their medical histories, but it does document that the deficiencies persisted across multiple survey cycles. The QAPI committee's failure to implement and sustain corrective actions resulted in ongoing noncompliance with federal and state regulations, as observed in the repeated survey findings.
Plan Of Correction
New Nursing Home Administrator met with the Interdisciplinary Team Facility Directors to review the current outstanding deficiencies and the facility plan to correct these deficiencies to maintain compliance with nursing home regulations. Current facility residents have the ability to be affected by this alleged deficient practice. Quality Assurance Performance Improvement Committee Meetings will continue to be held monthly to ensure quality care is being delivered to the residents residing at the facility and cited deficiencies including recurring deficiencies are being effectively addressed and corrected. New Nursing Home Administrator re-educated Quality Assurance Performance Improvement Committee members on the importance of facility and interdisciplinary team collaboration to correct cited facility deficiencies and ensure plans of correction improve the delivery of care and services to residents and effectively address recurring deficiencies, including care plan timing and revisions, providing quality care, ensuring resident environments are free from accident hazards, maintaining intravenous catheters and preventing issues with the accountability of controlled medications. The New Nursing Home Administrator will hold a weekly Department Head Meeting with the Interdisciplinary Team Facility Directors to review the progress and compliance of the current plan of correction audit process. Concerns and suggestions will be provided and reviewed as needed upon review of outstanding deficiency audits to ensure that improvements are being made and the facility is moving forward and progressing in its quality care being delivered to the residents residing at the facility. Weekly Department Head Meetings will continue until facility compliance is established. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at monthly meetings times nine months for results, areas of improvement and/or continuation of audits.