QAPI Program Lacked Tracking, Trending, and Systematic Review: The NHA stated that the QAPI committee had identified concerns such as return to hospital, weight loss, falls, and dietary menus, and that staff, residents, the grievance project, and resident council could bring items forward. However, the NHA could not explain how concerns were monitored, tracked, or trended on a regular basis, and could not provide documentation that the odor on A hall had been reviewed as a QAPI project. The NHA said it had not been a project and then stated it should have been; only falls and dietary menus were identified as issues seen in both QAPI and the annual survey.
The facility did not implement an effective QAPI program, as evidenced by a QAPI policy that lacked implementation and review dates, had not been approved by the QAPI team, and appeared to be a generic document from another company. The NHA confirmed the policy was not in use and could not explain the lack of approval. Although several PIPs addressing annual staff competencies, required CNA continuing education hours, and dietitian requirements had been presented to the QAPI committee, leadership was unaware that the facility would not achieve substantial compliance with these areas by the stated compliance date, affecting all residents.
The facility’s QAPI program failed to identify multiple systemic issues found during survey. The Administrator stated that problems with housekeeping, CNA competency evaluations, the Compliance and Ethics program, staff using electronic signatures and signing residents’ names instead of legal guardians, and lack of risk/benefit education before immunization consent were not identified through QAPI, despite the QAPI plan listing areas such as Maintenance, Housekeeping, Medical Record Integrity, Nursing Services, and Call Light Response.
QAPI program failed to identify and address systemic quality deficiencies. The NHA stated staffing was adequate and described weekend low staffing as a call-in problem, while also acknowledging the facility had not discussed a contingency staffing plan in QAPI. Review of performance improvement projects did not show staffing concerns or other systemic issues had been identified through the QAPI process, and the RDO stated, "Our QAPI program needs work."
QAPI failed to identify deficiencies in the facility's clean, comfortable, homelike environment and infection control program. The administrator stated no environmental concerns or infection control issues were identified through QAPI, and noted the facility had four different infection control preventionists over the prior year, with the most recent prior ICP not providing monthly reports to QAPI members.
The facility failed to maintain adequate QAPI/QAA policies and procedures for data collection, analysis, and feedback, with only a single outdated QA policy available and no other written guidance found. The NHA reported limited PIPs, including one for call lights and a discontinued pressure ulcer PIP, while survey review also found CNA pager issues, resident complaints that call lights were being shut off without follow-up, no documented antibiotic education for MDs or NPs, and the contracted pharmacist absent from QAPI meetings for more than 6 months.
The facility did not ensure its QAPI program identified and corrected quality deficiencies, particularly in dementia care. A resident with dementia did not receive individualized care despite interventions provided by her DPOA, and staff lacked knowledge on managing her stress responses. The QAPI committee failed to review data or develop action plans for identified concerns, and issues such as psychotropic medication use and staff training were not adequately monitored.
QAPI Program Failed to Identify and Correct Multiple Care and Documentation Deficiencies: The facility did not maintain an effective QAPI process, with failures in discharge and bed hold documentation, activity tracking, wound care, advance directive accuracy, and audit oversight. Surveyors found a resident sent to the hospital without documented bed hold/transfer/discharge paperwork, another resident with dementia lacking activity documentation and participation records, a resident with a facility-acquired stage 3 pressure ulcer receiving wound care that did not follow MD orders, expired wound supplies in the med room, and advance directive forms with missing or incorrect witness information that were still marked accurate on audit tools.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required, due to the absence of documentation or a described process for these quality improvement and assessment functions.
Surveyors found that the facility's QAPI program did not identify or address systemic issues in Infection Control and Pest Control, as evidenced by the presence of flying insects throughout resident areas and outdated pest control documentation. The QA committee was not monitoring these concerns, and there was no infection surveillance for legionella or compliance with local health department guidance.
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