Failure to Sustain QAPI Monitoring and Oversight for Repeat Deficiencies
Penalty
Summary
The facility failed to ensure effective implementation of its QAPI (Quality Assurance and Performance Improvement) and Risk Management Program policies, specifically in the areas of monitoring previously identified concerns and tracking performance to verify that improvement measures were realized and sustained. Despite having a policy that outlines a proactive approach to continual improvement and the use of data from various sources to identify and address areas needing attention, the facility did not adequately audit or oversee the corrective actions for previously cited deficiencies. Repeat deficiencies under F689 and F610 were identified during the current survey, which had also been cited in a prior complaint survey, indicating that prior corrective actions were not sufficiently monitored or maintained. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that, although audits and environmental modifications were conducted and corporate leadership provided support, there was a lack of awareness regarding ongoing issues, such as those related to residents' transfers. The DON confirmed that regional leadership was involved in reviewing reports before submission to the State Survey Agency, but the NHA acknowledged that the process of addressing these concerns was still ongoing and that further cultural change and improvement in QAPI practices were needed.