Ineffective QAA Program Fails to Correct Ongoing PASRR Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program that identified and corrected deficiencies related to providing a safe, clean, comfortable, homelike environment and ensuring completion of Level I PASRR screenings. Review of the facility’s QAPI purpose statement showed that the program was intended to monitor and sustain operational performance of clinical and non-clinical systems through self-identification and improvement of opportunities for improvement. However, record review of the Monthly QA/PI meeting agenda showed that although a Performance Improvement Plan (PIP) had been established for previously cited deficiencies involving F644 (Coordination of PASRR & Assessments) and F645 (PASRR Screening for Mental Illness and Developmental Disabilities) from a prior survey, the underlying issues were not effectively resolved. During a post-survey interview, the Administrator reported that the QAPI team had created a PIP in response to a previously identified PASRR system failure, but acknowledged that this PIP was not effective for residents who were already in the facility prior to the earlier survey. The Administrator stated that residents residing in the facility before that survey, whose diagnoses clearly qualified them for PASRR Level II reviews, had not been adequately addressed under the existing PIP. The Administrator confirmed that the same residents who had been identified as needing PASRR Level II screenings during the prior survey were again identified during the current recertification survey, demonstrating that the QAA program did not successfully implement corrective actions to resolve the PASRR-related deficiencies.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.