Failure to Monitor QAPI Plan of Correction for Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) committee implemented and monitored the effectiveness of its plan of correction for previously cited deficiencies at F552, F812, and F883. According to the facility's QAPI program, the committee is responsible for developing monitoring tools, creating plans of correction, and evaluating corrective actions to ensure residents receive necessary care. However, during an interview and document review, the Administrator was unable to provide documentation that the QAPI committee had monitored the effectiveness of the corrective actions for these deficiencies. Specifically, the plans of correction for F552 involved audits of informed consents and medication records, for F812 included monthly unit inspections and kitchen sanitation audits, and for F883 required maintaining a log of residents' immunization status and regular audits of immunization records. Despite these outlined actions, there was no evidence that the QAPI committee reviewed or evaluated the outcomes of these corrective measures, as required by the facility's own program.