Failure to Implement Effective QAPI Processes for Abuse Reporting
Penalty
Summary
The facility failed to carry out Quality Assurance activities to ensure that effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. Specifically, the CMS 2567 form identified a deficiency related to the failure to report an allegation of abuse. This issue was also identified during a subsequent complaint survey. The QAPI team met at least quarterly to discuss Performance Improvement Projects, and data was collected from various sources including Point Click Care, grievance forms, and vendor notes. Staff could report concerns through multiple channels, including anonymous compliance lines and written notes. Despite having a QAPI policy in place that outlined procedures for identifying and correcting quality deficiencies, the facility did not ensure that these processes were effectively implemented to address the failure to report abuse allegations. The deficiency persisted across multiple surveys, indicating that the mechanisms for tracking, prioritizing, and correcting such issues were not adequately followed or enforced. The report does not specify individual residents involved or their medical conditions at the time of the deficiency.