Failure to Implement Comprehensive QAPI Program and Oversight
Penalty
Summary
The facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed all systems of care, resulting in multiple deficiencies across several regulatory areas. Deficiencies included failure to ensure required regulatory visits, maintain appropriate staffing levels including an RN on-site for 8 consecutive hours daily, provide physician supervision and timely laboratory orders, and prevent neglect and administrative oversight failures, including those involving the Medical Director. These issues were identified through record review and interviews, with findings showing that the QAPI program did not systematically identify or address problems and opportunities for improvement in these critical areas. During several complaint and recertification surveys, the facility was cited for repeat and immediate jeopardy-level deficiencies, including those related to comprehensive care planning, abuse, accidents and hazards, insufficient nursing staff, failure to notify providers of lab results, and lack of administrative oversight by the Medical Director. Interviews revealed that the Medical Director had not participated in QAPI meetings or reviewed relevant reports and plans of correction, and the Administrator confirmed that the QAPI team was only working on select issues. The lack of effective QAPI oversight and engagement from key leadership contributed to the ongoing and repeated deficiencies.