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F0867
D

Repeated QAPI Failures in Addressing Quality Deficiencies

Indiana, Pennsylvania Survey Completed on 06-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address and correct recurring quality deficiencies, as evidenced by repeated citations in multiple areas. Despite developing plans of correction following a previous survey, the QAPI committee did not ensure sustained compliance with regulations related to the accuracy of assessments, care plan timing and revision, pharmacy services, and food safety. The current survey identified that the same deficiencies cited in the prior survey persisted, indicating that the QAPI committee's monitoring and oversight were ineffective. Specifically, deficiencies were again found under F641 for accuracy of assessments, F657 for care plan timing and revision, F755 for pharmacy services, and F812 for food safety. The facility's previous plans of correction had stated that these areas would be monitored by the QAPI committee, but the recurrence of these issues in the current survey demonstrates that the committee did not maintain compliance with the cited regulations.

See complete original report
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