Repeated QAPI Failures in Addressing Key Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The report details that, following a previous survey, the facility developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. However, the most recent survey identified repeated deficiencies in several key areas, including safety/accidents, palatable food, food procurement and storage, and infection control. Specifically, the QAPI committee was cited as ineffective in maintaining compliance with regulations regarding safety/accidents, as evidenced by a repeated deficiency under F689. Similarly, deficiencies related to palatable food (F804), food procurement and storage (F812), and infection control (F880) were also repeated, despite previous plans of correction that indicated these areas would be monitored by QAPI. The recurrence of these deficiencies demonstrates that the QAPI committee did not successfully address or sustain improvements in these areas. The findings are based on a review of the facility's plans of correction from a prior survey and the results of the current survey, which showed that the same issues persisted. The report references specific regulatory citations and indicates that the QAPI committee's monitoring and corrective actions were not effective in resolving the identified problems.
Plan Of Correction
The facility has an established Quality Assurance Performance Improvement Plan with monthly committee meetings to review ongoing performance issues, audits, and ways for improvement. The Nursing Home Administrator maintains meeting minutes and data collection. This survey plan of correction will be reviewed with the committee members and ongoing audits reported through the committee. Additional attention will be paid to correction of repeat deficiencies in the areas of safety, palatable food, food procurement, and infection control. Staff will be educated on the actionable items for correction to draw attention to needed compliance. Ongoing reporting will be reviewed at monthly meetings.