§483.75(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:
§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;
§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;
§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and
§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.
§483.75(b) Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:
§483.75(b)(1) Address all systems of care and management practices;
§483.75(b)(2) Include clinical care, quality of life, and resident choice;
§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.
§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.
§483.75(f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:
§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.
§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing; §483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;
§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.
§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and
§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.
§483.75(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.
§483.75(i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
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Observations:
Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.
Findings include:
Review of facility policy, "Quality Assurance and Performance Improvement (QAPI) Plan" revised April 2014, revealed that the facility will: "develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems ... This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees."
Further review of facility policy revealed, "Feedback, data systems and monitoring: Systems are in place to monitor care and services; care process and outcomes are monitored using performance indicators. These performance indicators are measures against benchmarks and targets that the facility has establishes; adverse events are tracked, monitored, and investigated as they occur." Under "Performance Improvement Projects" (PIPs) the policy indicated that, "PIPs involve systematically gathering information to clarify issues and to intervene for improvements."
Continued review revealed, "The following steps are employed or will be employed to support and enhance the facility QAPI program: Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include Clinical outcomes (pressure ulcers, infections, medication use, pain, falls, etc.); complaints from residents and families; re-hospitalizations; staff turnover and assignments; staff satisfaction; care plans; state survey deficiencies; and MDS assessment data."
Review of QAPI Committee Meeting records, failed to reveal documentation of meeting minutes for the months of May, June, July, August 2023. The facility failed to provide further documentation of QA meetings and attendees during the survey.
Review of QAPI Committee Meeting records, dated "September 2023; Q3 October 24; November 16; December 14, 2023; January 11, 2024," revealed that an attendance log and a PIP (Performance Improvement Project) log were provided. No items were noted on the PIP log.
Review of QAPI Committee Meeting records, undated chart titled, "Quality Assurance and performance Improvement Action Plan" revealed the following topics were noted: Resident centered Care Plans; Infection Control Immunizations; Stand up and morning meeting forms" and had a documented tentative completion date of March 1, 2024. No documentation or tracking events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation for the months of May, June, July, August, September, October, and November 2023, were provided during survey for the topics mentioned above.
Review of QAPI Committee Meeting records, titled "Nursing QAPI December 2023" revealed that the following topics were noted: Infection Prevention; Staff Education; Comprehensive Care Plans; Falls; UDA; and POC completion." No documentation or tracking events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation for the months of May, June, July, August, September, October, and November 2023, were provided during survey for the topics mentioned above.
Interview with the Nursing Home Administrator on February 23, 2024, at 2:46 p.m. confirmed that he had no further data to provide related to the facilities QAPI program.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(e)(2) Management
| | Plan of Correction - To be completed: 03/15/2024
1. No residents were cited by this F-Tag. 2. QAPI Minutes for the last 6 months will be reviewed. 3. The IDT Team will be educated regarding the new QAPI process. 4. The RDCS/Designee will audit the QAPI minutes monthly x6 months to ensure that an appropriate QAPI program is occurring per regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee
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