Repeat Deficiency in MDS Assessment Accuracy Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior corrective measures. Despite having a QAPI plan that required ongoing actions, measurement of success, and tracking of performance, the facility did not implement adequate policies or monitoring to ensure improvements were maintained. A deficiency for inaccurate Minimum Data Set (MDS) assessments, previously cited during an earlier recertification survey, was cited again during the current survey, indicating that the facility did not provide sufficient auditing and oversight. The administrator attributed the repeat deficiency to lapses in maintaining documentation accuracy during transitions in management and MDS staff roles.