§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 corrections for State Survey and Certification (Department of Health) surveys ending February 16, 2023; March 9, 2023; March 29, 2023; June 6, 2023; July 13, 2023; August 23, 2023; September 15, 2023; October 18, 2023; and November 6, 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 14, 2024, identified repeated deficiencies related to a failure to notify residents' physician/responsible parties regarding changes in condition, to provide a clean and homelike environment, to ensure that Minimum Data Sets (MDS, a mandated assessment of a resident's abilities and care needs) assessments were accurate upon submission, develop individualized care plans, to prevent accident hazards, to prevent issues with oxygen therapy, to prevent issues with the accountability of controlled medications (drugs with the potential to be abused), properly store and label medications, to serve palatable food at appropriate temperatures, store and prepare food under sanitary conditions, and to ensure proper infection control practices were followed.
The facility's plan of correction for a deficiency regarding notifying the physician/responsible party about changes in condition, cited during the survey ending February 16 and August 25, 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 was ineffective in maintaining compliance with the regulation regarding physician/responsible party notification.
The facility's plans of correction for deficiencies regarding providing a clean and homelike environment, cited during the surveys ending February 16, 2023 revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F584, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to maintaining a clean and homelike environment.
The facility's plan of correction for a deficiency regarding a failure to ensure that MDS's were accurate upon submission, cited during the survey ending February 16, 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 F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.
The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending February 16, 2023, revealed that audits would be completed. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan.
The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the surveys ending February 16, March 9, and October 18, 2023, revealed that the facility developed plans 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 F689, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to safety and accident-free enviornment's.
The facility's plan of correction for a deficiency regarding failure to provide respiratory care and treatment as ordered by the physician, cited during the survey ending July 13, 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 F695, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to administering oxygen as ordered.
The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending February 16 and October 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.
The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during the survey ending February 16, 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 F761, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly.
The facility's plan of correction for a deficiency regarding food palatability, cited during the survey ending March 29 and September 15, 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 F804, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food palatability.
The facility's plan of correction for a deficiency regarding food storage and labeling, cited during the survey ending February 16 and November 6, 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 F812, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food storage and labeling.
The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending February 16 and June 6, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F880, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to infection control.
Refer to F580, F584, F641, F656, F689, F695, F755, F761, F804, F812, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
| | Plan of Correction - To be completed: 03/07/2024
1. Facility is unable to fix the Quality Assurance audits at the time of the survey. 2. No other issues identified. 3. Nursing Home Administrator will educate the all department managers on the quality assurance process improvement policy. Nursing Home Administrator or designee will audit the Quality Assurance Process Improvement meeting monthly to verify all audits are reported, analyzed and a process improvement plan implemented if needed.
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