Failure to Identify and Address Key Deficiencies Through QAPI
Penalty
Summary
The facility failed to identify and address multiple areas of improvement through its Quality Assurance and Performance Improvement (QAPI) program. Surveyors identified five specific concerns that were not proactively recognized by the facility's QAPI process: Advanced Beneficiary Notification (ABN), care plan updates, medication consents, proper reporting of abuse, and Preadmission Screening and Annual Resident Review (PASARR). During an interview, the Nursing Home Administrator (NHA) acknowledged that while there were Performance Improvement Plans (PIPs) in progress for wound care and weight measurement, PIPs for ABN and medication consents were only initiated after these issues were brought up by the survey team. The NHA also reported ongoing issues within the MDS department, which impacted timely ABN issuance, effective care planning, PASARR coordination, and completion of medication consents. The NHA described that the Interdisciplinary Team (IDT) met daily to identify concerns and that staff could report issues to unit managers, IDT members, or the compliance officer, but there was no anonymous reporting mechanism. The NHA was unable to explain why the QAPI program had not previously identified the concerns found during the recertification survey. The lack of proactive, system-level interventions and failure to identify these deficiencies through the QAPI process placed residents at risk for harm.