Failure to Monitor and Evaluate Coffee Temperature Compliance
Penalty
Summary
The QAPI committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying the need to monitor coffee temperatures. The facility's QAPI policy required systems to monitor care and services, including the use of performance indicators to track care processes and outcomes. An in-service training instructed staff to serve coffee at temperatures between 120 to 140 degrees Fahrenheit. However, audit documentation showed that on one occasion, coffee was served at 149.1 degrees Fahrenheit, which was outside the specified range, and no corrective action was documented. Interviews with the Dietary Manager and the DON confirmed that while coffee temperatures were being recorded and audit forms were placed in the QAPI binder, there was no staff member assigned to monitor or evaluate the recorded temperatures or the effectiveness of the in-service training. There was no documented evidence that the QAPI committee reviewed or acted upon the audit findings to ensure compliance with the established temperature guidelines.