Failure to Sustain Infection Control QAPI Activities
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and address a systemic issue with the Infection Prevention & Control Program, as evidenced by repeat deficiencies cited during consecutive annual surveys. Despite a history of infection prevention and control deficiencies, the facility was unable to provide documentation of an active Process Improvement Plan (PIP) or current audits related to infection prevention and control at the time of the survey. During an interview, the Administrator acknowledged that monitoring for a previous plan of correction had been discontinued several months prior. The facility's policy requires the QAA&C Committee to review data, implement process improvement plans, and monitor their effectiveness, but there was no evidence that these steps were being followed for infection prevention and control.