cms_WY: 58
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
58 | SUBLETTE CENTER | 535017 | 333 N BRIDGER AVE | PINEDALE | WY | 82941 | 2018-02-15 | 865 | E | 0 | 1 | 3QMW11 | Based on review of the facility's written QAPI plan and staff interview, the facility failed to ensure the plan contained all the required elements. The findings were: Review of the facility's plan titled QAPI Policy showed it did not describe the process for identifying and correcting quality deficiencies. The policy listed the members of the QAPI oversight team and listed the frequency of meetings. Specifically, the plan lacked the following: a. Tracking and measuring performance. b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing quality deficiencies. d. Analyzing underlying causes of systemic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities. f. Monitoring the effectiveness of corrective action, and revising as needed. During an interview on 2/15/18 at 8:07 AM the QAPI coordinator stated the facility was in the process of revising the written QAPI plan/policy and confirmed the current policy/plan did not contain all the required elements. | 2020-09-01 |