Repeat Deficiencies Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) and Quality Assurance Performance Improvement (QAPI) group failed to provide effective oversight and implementation of the facility's plan of correction for previously identified deficient practices. This lack of effective oversight resulted in repeat deficiencies in several key areas, including activities of daily living (ADL) care for dependent residents, formulation of advance directives, infection prevention, quality assurance and performance improvement, food storage, medication error rates, and psychotropic medication use. The repeat deficiencies were identified during the 2024 recertification survey, indicating that the issues had not been adequately addressed since the prior survey. During interviews, the Administrator acknowledged that the QAPI committee was currently focused on falls and behavior management, but recognized that the committee could improve its approach to addressing repeat deficiencies. The facility's policy and procedure for QAPI, dated 2022, outlined a comprehensive program intended to monitor and improve the quality of resident care, but the findings indicate that the program was not effectively implemented to resolve the identified issues. No specific residents or patient medical histories were detailed in the report.