Repeated QAPI Program Deficiencies and Failure to Report/Investigate
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during multiple complaint investigations. Specifically, the facility was cited for failures to report and investigate incidents, with deficiencies noted on several occasions, including failures to report (Tag 609) and failure to investigate (Tag 610). These repeated deficiencies were documented over a period spanning from August 2023 to June 2025, indicating ongoing issues with the facility's processes for identifying and correcting quality problems. A review of the facility's QAPI/QAA plan revealed that, while a policy document existed with a stated purpose of continuous quality improvement and staff participation, the actual practices did not prevent the recurrence of the same deficiencies. Staff interviews and policy reviews confirmed that the facility's approach was not effective in addressing or preventing the cited issues, as the same types of deficiencies continued to be identified during subsequent complaint investigations.