cms_SD: 51
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 51 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 867 | J | 0 | 1 | CZRE11 | Based on interview and plan review, the provider failed to ensure an effective quality assurance performance improvement (QAPI) program had been implemented and followed through to develop and implement corrective actions for all residents. Findings include: 1. Interview on 03/28/18 at 1:30 p.m. with the administrator, Minimum Data Set (MDS) assessment coordinator, and registered nurse (RN) [NAME] revealed: *They tried to have monthly QAPI meetings. *The committee included the leadership team. *The medical director attended at least quarterly. *They used various methods and information to select actions of the QAPI committee: -Past surveys. -CASPER and quality measure (QM) reports. -They always reviewed certain things such as infection control, falls, and pressure injuries. --For pressure injuries they discussed rates in general. *The QAPI committee started a performance improvement project (PIP) for specific focus areas they were working on. *The current PIPs were for call lights and medication destruction. -Call lights was a concern that was brought up by the residents in their council meeting. -Medication destruction was an area the director of nursing (DON) thought still needed some work. *There had been quite a few changes in the leadership roles in the facility. *The administrator had started in his role in (MONTH) (YEAR). *The DON had started her role in (MONTH) (YEAR). *The MDS nurse was also new to her role within the last year. *RN [NAME] would be learning more about QAPI and being more involved in the future. Continued interview and record review of the attendance sheets for the QAPI meetings from (MONTH) (YEAR) through 3/28/18 revealed: *The administrator stated he was unable to find several of the attendance sheets. -When the new administration took over things changed. -For some reason they stopped keeping track of the attendees. *Their last list of attendees prior to the (MONTH) (YEAR) meeting was on 8/22/17. *The administrator stated they had a meeting in (MONTH) (YEAR), but there was no record of it. *They had no meeting in (MONTH) (YEAR). *During the 1/30/18 meeting they started keeping track of attendees again. -That was when they had noticed it was not getting done. *They had no QAPI meeting in (MONTH) (YEAR) or in (MONTH) (YEAR) yet. Review of the copies of attendees for QAPI from (MONTH) (YEAR) through 3/27/18 revealed:*There was no attendees listed for the 4/28/17 meeting. *The medical director had not attended the 5/23/17 meetings. *There were meetings held on 6/20/17, 7/18/17, 8/22/17. *There were copies of email invites for the meetings on 9/19/17 and 10/31/17, but there was no list of who actually attended. *They had no meeting in (MONTH) (YEAR). *The (MONTH) (YEAR) meeting had not been attended by the physician. -There was no proof the medical director had attended a meeting since (MONTH) (YEAR). Continued interview with the administrator, MDS coordinator, and RN [NAME] regarding QAPI revealed:*The leadership changes might have contributed to the concerns with the QAPI program. *They stated the medical director liked to attend and participated in the meetings. *There were only the two current PIPs, because they did not want to get overwhelmed with too many at one time. -They were planning to add more PIPs at the next meeting. *When they had their quarterly meetings with the medical director those were more in-depth discussions than during the monthly meetings in-between. -If a PIP needed to be added at a monthly meeting they would do that. *PIP were separate committees that reported to the QAPI committee. -They were trying to get direct care staff involved in the PIP committees. *They confirmed when they used QM data to find areas that needed to be worked on that would have been past concerns, since it was generated from resident MDS assessments. *They agreed QAPI should have been a proactive approach to problems and not reactive to old data. *They currently did not have a specific QAPI template they followed but were hoping to get that changed in the future. *When asked if any of the audits or follow-up from the previous surveys in (YEAR) had still been a part of the QAPI meetings they stated: -They thought they were done with those items. --Most had run their course. -They were aware the last survey in (MONTH) (YEAR) identified system concerns with pressure injuries. --The current survey found concerns again with pressure injuries. *The administrator stated the current leadership was asked to review the past deficiencies that would have been related to their department. *The MDS coordinator stated the president of the Custer market had indicated they should be looking back at the previous surveys and making that a part of the QAPI plan. -She thought that was back in (MONTH) (YEAR). *They felt corporate staff and consultants were available to them if they reached out for help. *The administrator stated QAPI should have been a focus during the day-to-day operation for everyone working there. *They confirmed they had not actively been working on PIPs for some of the concerns surveyors had identified including: -Pressure injuries. -Falls and interventions. -Investigations into residents' incidents and accidents. *The MDS coordinator stated falls had been a PIP in (MONTH) (YEAR), and they were doing better then. -It was not currently a PIP. -QAPI reviewed falls in general but not necessarily the interventions. *The administrator oversaw this facility and another long-term care facility. -He divided his time between the two and felt it worked well. -He was available to both facilities anytime they asked either in-person or by phone. -He felt the staff kept him informed and aware of what was happening. *They confirmed their QAPI program had not been effective in the past, and they would be working towards improvement. Review of the provider's undated QAPI Plan for (facility name) revealed:* .All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services.*Our QAPI plan includes policies and procedures to: -Identify and use data to monitor our performance. -Establish goals and thresholds for our performance. -Utilize resident, staff and family input. -Identify and prioritize problems and opportunities for improvement. -Systematically analyze underlying causes of systemic problems and adverse events. -Develop corrective action or performance improvement activities. *The QAPI committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. *The administrator has responsibility and is accountable to the board of directors and our corporation for ensuring that QAPI is implemented throughout our facility . *All department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representatives (if appropriate) and three additional staff will provide QAPI leadership by being on the QAPI committee . *The QAPI committee will meet monthly . * .The QAPI committee prioritize opportunities for improvement and determine which performance improvement projects will be initiated . *Our organization will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention . *Our QAPI committee will prioritize topics for PIPs based on the current needs of the resident and our facility. Priority will be given to areas that are problem-prone . | 2020-09-01 |