§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 ensure that corrective plans to improve and/or correct quality deficiencies effectively addressed recurring deficiencies and ensured that the facility maintained compliance with nursing home regulations.
Findings include:
The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending December 1, 2023; June 30, 2023; and March 23, 2023, revealed that the facility developed plans of correction 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 8, 2024, identified repeated deficiencies related to notification of changes, developing comprehensive care plans, updating and revising care plans, providing services to maintain adequate nutrition, ensuring that food was properly stored, and ensuring that the medical record was complete and accurately documented.
The facility's plans of correction for deficiencies regarding notification of changes, cited during the survey ending December 1, 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 F580, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding notification of changes.
The facility's plans of correction for deficiencies regarding developing comprehensive care plans, cited during the surveys ending June 30, 2023, and March 23, 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 F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding the development of a comprehensive care plan to meet the care needs of residents.
The facility's plan of correction for a deficiency regarding revision of care plans, cited during the survey ending March 23, 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 F657, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the revision of care plans to meet the care needs of residents.
The facility's plan of correction for a deficiency regarding services to maintain nutritional status, cited during the survey ending June 30, 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 F692, revealed that the QAPI committee was ineffective in maintaining compliance with services to maintain nutritional status.
The facility's plan of correction for a deficiency regarding labeling, storing, preparing and serving food under sanitary conditions, cited during the survey ending March 23, 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 was ineffective in correcting deficient practices related to labeling, storing, preparing and serving food under sanitary conditions.
The facility's plan of correction for a deficiency regarding complete and accurate documentation in the medical record, cited during the survey ending June 30, 2023, and March 23, 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 F842, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding complete and accurate documentation in the medical record.
Refer to F580, F656, F657, F692, F812, F842
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
| | Plan of Correction - To be completed: 03/27/2024
1. No residents were identified regarding this deficiency. 2. Residents residing in the facility have the potential to be affected by the identified deficient practice. The Administrator/designee will continue to routinely monitor the plan of correction for compliance and address any needed interventions. 3. The Administrator will retrain members of the Quality Assurance and Performance Improvement Committee on problem identification and initiation or continuance of identified areas brought forth to the Quality Assurance Performance Improvement Committee. 4. The Quality Assurance Performance Improvement Committee will audit future plans of corrections to ensure they are compliant with all aspects of the cited deficiency. The results will be reviewed at the Quality Assurance and Performance Improvement Committee meetings.
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