Repeat Deficiencies Due to Ineffective QAA Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and did not implement the plan of correction for deficiencies identified during the previous recertification survey. This lack of oversight resulted in repeat deficiencies in several critical areas, including resident rights, advance directives, Medicare coverage notification, notice of transfer requirements, accuracy of assessments, implementation of care plans, social services, pharmacy services, medication storage, and infection control and prevention. The administrator acknowledged during an interview that there were repeat deficiencies and indicated that the facility's audits and chart reviews by social workers were not sufficiently robust. A review of the facility's Quality Assurance and Performance Improvement (QAPI) policy revealed that the committee is responsible for developing and implementing plans of action to correct identified quality deficiencies. However, the report indicates that the QAA committee did not fulfill these responsibilities, as evidenced by the recurrence of the same deficiencies from the previous survey. There is no mention of specific residents or their medical conditions in relation to these deficiencies.