§483.75(c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:
§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.
§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.
§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.
§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.
§483.75(d) Program systematic analysis and systemic action.
§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.
§483.75(d)(2) The facility will develop and implement policies addressing: (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.
§483.75(e) Program activities.
§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.
§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.
§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.
§483.75(g) Quality assessment and assurance.
§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
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Observations:
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending February 24, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 1, 2024, identified repeated deficiencies related to a failure to complete Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs) accurately, to develop comprehensive care plans, following physician's orders, and to prepare and store food under sanitary conditions.
The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending February 24, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding completing accurate MDS assessments.
The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending February 24, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.
The facility's plan of correction for a deficiency regarding a failure to follow physician's orders, cited during the survey ending on February 24, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders.
The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending February 24, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding preparing and storing food under sanitary conditions.
Refer to F641, F656, F684, F812.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
| | Plan of Correction - To be completed: 03/14/2024
1. The facility Quality Assurance Performance Improvement committee will continue to be held monthly. The committee will meet the expectations of the facility policy to ensure follow-up on repeat deficiencies. 2. The Administrator will provide re-education on the Quality Assurance Performance Improvement committee process and the expectations to active committee participants as outlined in the above-mentioned policy. 3. The committee failed to successfully implement plan of corrections for previously identified areas by not reviewing audit findings and making any corrective recommendations. To assure compliance of the plan of correction, department head committee members will present their specified areas at the committee meetings for discussion, committee recommendations, effectiveness and implementation of corrective actions. These presentations will include audit tools utilized to address areas of the plan of correction and will be reported on a monthly basis. Committee members will implement recommendations as discussed and detailed by the committee. Participating committee members will follow up on recommendations to assure continued compliance. Any outlying findings will be corrected and reported back to the committee for further discussion/ recommendations. 4. Monthly minutes from the Quality Assurance Performance Improvement committee will be forwarded to the Regional Clinical Nurse for review and recommendations. 5. Date of compliance 3/14/2023
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