QAA Committee Failed to Address Repeated Systemic Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and address repeated systemic problems that had been previously identified during the last survey process. Specifically, the committee did not recognize or implement corrective actions regarding staff failure to notify the medical doctor of any change in residents' conditions and the inaccuracy of the Minimum Data Set (MDS) assessments for residents. These issues were confirmed during an interview with the Administrator, who acknowledged that the QAA committee did not identify these ongoing problems during the current survey process. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the committee is responsible for developing, implementing, and maintaining a data-driven program focused on care outcomes and quality of life. The policy also states that the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities. Despite these requirements, the committee failed to detect and address the deficiencies related to physician notification and MDS accuracy, affecting all 102 residents in the facility.