Repeated Deficiencies in QAPI and QAA Implementation
Penalty
Summary
The facility failed to ensure effective implementation and sustainability of its Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities, as evidenced by repeated deficiencies identified during multiple recertification surveys. Specifically, the facility was cited for ongoing issues related to food procurement, storage, preparation, and sanitary practices, as well as resident rights concerning dignity during dining. These deficiencies were noted in both the previous and current recertification surveys, indicating a pattern of non-compliance and insufficient corrective action over time. During a QAPI review, it was confirmed that the QAPI committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had met recently and reviewed activities and goals related to previously cited deficiencies. Despite having a documented policy outlining the purpose and scope of the QAA committee and QAPI program, the facility continued to exhibit repeated deficient practices in the same areas, demonstrating a lack of effective and sustained improvement.