Repeat Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies across multiple survey cycles. Specifically, deficiencies were identified in care plan timing and revision (F657), sufficient nursing staff (F725), food procurement, storage, preparation, and service sanitation (F812), and infection control (F880) during a recertification and complaint survey. These same deficiencies were cited again in a subsequent survey, indicating that the facility did not adequately address or prevent recurrence of these issues through its QAPI processes. Interviews and policy reviews revealed that, although the facility had a QAPI policy outlining the responsibilities of the QAPI Committee—including data collection, root cause analysis, and communication with leadership—the program was not effective in resolving or preventing the repeat deficiencies. The administrator reported that the facility worked on the previously cited deficiencies through QAPI, but the recurrence of the same issues suggests that the actions taken were insufficient to achieve sustained improvement.