Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies during the current recertification survey. Survey findings revealed that the facility had ongoing issues in several areas, including the development and implementation of comprehensive care plans, care plan timing and revision, accident hazards and supervision, labeling and storage of drugs and biologicals, staff competency, and infection prevention and control. These deficiencies were identified through staff interviews, review of CMS-2567 reports, and facility policy review. Repeated citations were documented across multiple surveys, with deficiencies noted for failing to develop and update care plans for residents prescribed medications such as insulin and antidepressants, as well as for residents with specific needs like smoking assessments and code status updates. There were also failures in ensuring appropriate supervision and interventions for residents at risk for accidents, falls, and elopement, as well as lapses in infection control practices, such as improper gloving and catheter care. The facility's QAPI policy outlined responsibilities for oversight and monitoring, but the recurrence of similar deficiencies indicated that the processes in place were not effective in preventing or correcting these issues. The CASPER report and survey history showed that the same types of deficiencies had been cited repeatedly over several years, including in previous annual recertification surveys. The facility's QAPI and QAA activities, as described in their policy, were intended to systematically identify and address problems, but the persistence of these deficiencies demonstrated that the facility did not adequately implement or sustain effective corrective actions to resolve the underlying issues.