Repeat Deficiencies in QAPI Oversight and Medication Error Rate
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee effectively conducted performance improvement activities to sustain prior corrective measures. Despite having a QAPI policy that required ongoing actions, measurement of success, and tracking of performance, the facility was cited for repeat deficiencies in medication error rate (F759) and QAPI processes (F867) during the current and previous recertification surveys. The report notes that there was insufficient auditing and oversight to prevent recurrence of these deficiencies, indicating that the QAPI committee did not maintain adequate follow-up or monitoring to ensure sustained improvement. The Administrator confirmed that the QAPI committee met monthly and reviewed departmental audits, with Performance Improvement Plans (PIPs) developed for identified concerns. However, the Administrator, who had only recently returned to the facility, was unable to specify where the process failure occurred. She acknowledged that recent changes in ownership and administration may have contributed to a loss of focus, but also recognized that the performance improvement process should have continued regardless of staff changes. The repeat citations and lack of sustained improvement measures were directly observed by surveyors during the current survey.