Failure to Implement QAPI Process for Repeated Deficiencies
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified deficient practices, resulting in continued noncompliance. During a survey, it was found that the facility had been cited for deficiencies related to food palatability, proper garbage/refuse disposal, and infection prevention and control in a prior survey, and these same issues were cited again in a subsequent survey. The Administrator acknowledged that while survey results were used to identify areas needing improvement, the facility had not developed or implemented performance plans for these deficiencies. Specifically, there were no metrics or monitoring tools for food palatability, garbage disposal issues were not revisited or addressed with new corrective measures, and infection control improvements were limited to education on enhanced barrier precautions without broader performance improvement projects. Review of the facility's QAPI policy indicated that all identified problems should be addressed and prioritized, with actions documented and monitored through QAA Committee meetings. However, interviews and record reviews revealed that the facility did not follow its own policy, as there was a lack of documented improvement plans and ongoing monitoring for the cited deficiencies. This failure to act on identified problems through the QAPI process led to repeated citations for the same issues affecting all residents in the facility.