Repeated Non-Compliance Due to Ineffective QAPI and Lack of Sustained Improvement
Penalty
Summary
The facility failed to demonstrate sustained performance improvement in addressing previously identified quality deficiencies, resulting in repeated non-compliance across multiple regulatory areas. During the most recent recertification survey, surveyors found ongoing issues in Resident Rights, Resident Assessment, Quality of Life, Quality of Care, Dietary, and Infection Control. Department heads, including the Food Services Manager, Activities Director, and Social Worker, were unable to provide specific details on how the Quality Assessment and Performance Improvement (QAPI) committee proactively addressed or monitored these deficiencies to prevent recurrence. For example, the Food Services Manager and Administrator could not explain why dietary staff continued to violate food safety protocols, and the Activities Director was unable to account for repeated failures to provide 1:1 in-room activities for certain residents as required by their care plans. Interviews revealed that while some staff were aware of past deficiencies and had implemented Performance Improvement Plans (PIPs), there was a lack of ongoing monitoring and follow-up to ensure that improvements were sustained. The Social Worker, for instance, was solely responsible for reviewing preadmission screening assessments for a large number of residents and did not seek additional support, despite repeated deficiencies in this area. Similarly, the Administrator and DON acknowledged that current issues with nursing care, such as failures in PICC line management, mirrored those cited in previous surveys, but could not detail how QAPI ensured departments were preventing repeated deficiencies. The report highlights that the facility's approach to quality improvement was largely reactive, with department heads and leadership unable to demonstrate proactive strategies or sustained monitoring to address and prevent repeated non-compliance. The lack of detailed, department-specific QAPI initiatives and insufficient follow-through on previously identified issues contributed to ongoing regulatory deficiencies in key areas affecting resident care and services.