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.
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."
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.
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.
The facility did not implement or maintain an effective QAPI program, as evidenced by the absence of data collection, performance improvement projects, action plans, and regular team participation. The DON reported no ongoing QAPI activities and expressed uncertainty about the program's purpose, while the NHA and IP were not present at a recent QAPI meeting.
The QAPI committee did not identify or address key quality issues, including call light response, grievance documentation, timely and accurate MDS submissions, antibiotic stewardship, infection control, and maintenance of complete and accurate medical records. Policies and procedures were outdated or missing, and the QAPI plan was incomplete, affecting all residents in the facility.
The facility did not identify or address several critical areas—such as ABN, care plan updates, medication consents, abuse reporting, and PASARR—through its QAPI program. Issues within the MDS department contributed to these deficiencies, and the QAPI process failed to proactively recognize them before they were identified by surveyors.
The facility did not maintain an effective QAPI program, failing to identify and address issues such as hot water temperature and call light accessibility. Despite resident complaints about the lack of hot water, there was no documented follow-up or ongoing monitoring in QAPI records, and the administrator was unaware of any related discussions or performance improvement plans.
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