Repeat Deficiencies Due to Ineffective QAA Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the plan of correction for deficiencies identified during the most recent recertification survey in 2024. This failure resulted in repeat deficiencies in the areas of pharmacy services, quality of care, and infection control. During a review of the facility's Statement of Deficiencies, it was found that these issues persisted despite the existence of a QAPI program intended to monitor and improve quality standards. An interview and record review with the Administrator revealed that although the QAPI program was ongoing and designed to analyze data and identify concerns, the Administrator, who had only recently started at the facility, was unsure why the deficiencies were repeated. The facility's policy stated that the QAPI committee was responsible for identifying and addressing care and quality issues and implementing action plans, but the repeat deficiencies indicated that these processes were not effectively carried out.