Failure to Convene QAPI Meeting and Implement Directed Plan of Correction
Penalty
Summary
The facility failed to take actions aimed at performance improvement by not convening a Quality Assessment and Assurance (QAPI) meeting to address quality deficiencies identified during a previous survey. After the survey exited, the facility did not systematically identify, report, track, investigate, or analyze the cited deficient practice. The last QAPI meeting was held prior to the survey, and no subsequent meeting was convened within the required timeframe after receiving the statement of deficiencies. Additionally, the facility did not conduct a risk assessment to determine the causes of non-compliance. The facility also did not complete or implement the Directed Plan of Correction imposed with a Category 1 remedy by the deadline set by the State Agency. The Administrator confirmed that no QAPI meeting had been held to address the negative findings due to the Director of Nursing being on vacation. There was no evidence that the facility addressed or implemented the required corrective actions as directed by the State Agency.