Repeat Deficiencies Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies identified during multiple annual, revisit, and complaint surveys over a three-year period. Deficiencies cited included issues with notification of changes, quality of care, tube feeding management, infection control, development and implementation of abuse/neglect policies, accidents and hazards, nutrition/hydration status maintenance, care plan timing and revision, and services provided meeting professional standards. These deficiencies were documented through reviews of the Department of Inspections, Appeals, and Licensing website, which showed repeated citations for the same or similar issues across several surveys. Despite having a QAPI plan and procedures in place, the facility's actions did not prevent the recurrence of these deficiencies. The QAPI documentation described a structured, data-driven approach involving interdisciplinary teams and input from residents and staff, with processes for identifying and addressing quality care and process improvement opportunities. However, the repeated nature of the cited deficiencies indicates that the QAPI program was not effectively implemented or sustained, resulting in ongoing noncompliance with regulatory requirements related to quality assurance and performance improvement.