Repeated Deficiencies in MDS Accuracy and Medication Storage Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee failed to implement effective action plans to correct previously identified quality deficiencies. Specifically, the facility was cited for repeated deficiencies in the areas of F641 (Accuracy of assessment) and F761 (Label/Store drugs and biologicals). The facility did not accurately code the Minimum Data Set (MDS), particularly in section B regarding corrective lenses, and failed to ensure medications were securely stored. These issues were identified during a recertification survey and had been cited in the facility's survey history. Despite the QAPI committee meeting monthly and including a broad range of facility leadership and staff, the committee did not adequately monitor or address these ongoing problem areas. The committee's continued evaluation of their performance improvement projects did not result in effective corrective actions, as evidenced by the recurrence of the same deficiencies. At the time of the survey, there were 156 residents residing in the facility.