QAA Committee Failed to Identify and Address Deficient Trends in QAPI Plan
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and include certain quality deficiencies in the Quality Assurance Performance Improvement (QAPI) plan. Specifically, during a recertification and relicensing survey, surveyors identified trends related to resident nail care, grooming, and annual staff performance evaluations that were not being monitored or addressed by the QAA Committee. The Director of Nursing (DON) confirmed that the QAPI team was primarily focused on call lights, falls, and urinary tract infections, and had not recognized or prioritized the additional deficient trends found by surveyors. Facility policy requires the QAPI program to address all systems and practices affecting residents, including clinical care, quality of life, and staff performance, and to prioritize high-risk or problem-prone areas. However, the QAA Committee did not identify or include the surveyor-identified trends in their QAPI plan, contrary to policy expectations. This omission was acknowledged by the DON during interviews and was supported by a review of the facility's QAPI documentation.