Failure to Maintain Effective QAPI Program and Monitoring Documentation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. Previous surveys had resulted in enforcement actions for deficiencies related to abuse and neglect, failure to investigate and correct alleged violations, and accident hazards. Despite these repeated issues, the QAPI committee did not systematically monitor or document the progress of corrective actions, and there was a lack of sustained oversight, particularly due to frequent changes in the Director of Nursing (DON) position. The Nursing Home Administrator (NHA) was unable to provide documentation of completed Performance Improvement Plans (PIPs) or explain how substantial compliance was determined for previous citations. The facility's own guidelines required ongoing, systematic monitoring of performance indicators and data collection for at least one year, but these processes were not followed. The NHA acknowledged that the DON was responsible for ensuring nursing-related corrective actions were active and sustained, but admitted there was a failure to track and implement these measures. As a result, the facility did not have an effective system in place to ensure that identified problems were corrected and prevented from recurring, and monitoring documentation was incomplete or missing.