Failure to Follow Plan of Correction and Monitor Quality Deficiencies
Penalty
Summary
The facility failed to correct and monitor previously identified quality deficiencies, as evidenced by a revisit survey that found noncompliance with three specific deficiencies (F610, F842, and S1320). Record review and staff interviews revealed that the facility did not follow its plan of correction for these deficiencies, with S1320 remaining out of compliance. The Director of Nursing identified the Administrator as the Quality Assurance (QA) contact person, and the Administrator confirmed that QA meetings were held monthly. However, when questioned, the Administrator stated that the QA team did not specifically discuss the citations or the progress of the plan of correction, despite the plan indicating that the QAPI team would review all audits. The surveyor noted ongoing concerns related to a qualified social worker.