Repeated QAPI Failures in Addressing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve care and services were effectively implemented. Despite developing plans of correction after previous surveys, the facility continued to have repeated deficiencies in several areas, including maintaining a safe, clean, and homelike environment, completing accurate Minimum Data Set (MDS) assessments, properly labeling and storing drugs and biologicals, and ensuring proper food procurement. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were identified in subsequent surveys, indicating that the committee did not successfully implement or sustain corrective actions. Specific deficiencies cited in the current survey included issues under F584 (environment), F641 (MDS assessments), F761 (labeling and storage of drugs and biologicals), and F812 (food procurement). The facility's previous plans of correction for these areas involved conducting audits and reporting findings to the QAPI committee, but the recurrence of these deficiencies demonstrates that these actions were not effective in achieving ongoing compliance with regulatory requirements.