Frequently Cited Deficiencies and Common Compliance Strategies - Quality Management Program

This is for informational purposes only. Following this guidance does not guarantee that deficient practice will not be cited on the survey visit. What follows are examples of some, but not all causes for deficient practice. This guidance is not intended to be the best or the only way to be compliant.
6 CCR 1011, Chapter XXVI, section 6.14 – Quality Management Program

“Every HCA shall establish a quality management program appropriate to the size and type of agency that evaluates the quality of consumer services, care and safety, and that complies with the requirements set forth in 6 CCR 1011, Chapter II, section 3.1.”
Common Causes of Deficient Practice
  • Scenario: No action is taken to address identified problems.
Review of Quality Management Program (QMP) documentation for chart audits completed by the agency revealed missed visits were routinely occurring, and showed the reason why missed visits occurred was not consistently documented. Although the problems were identified, no action was taken by the agency to address the problems. As a result, deficient practice related to an incomplete QMP was cited.
Excerpt of a deficiency list
"…During an interview on 08/25/16 at 2:35 p.m., the Director of Nursing (DON) stated the agency had identified documentation, staffing and missed visits as current problems through record review. However there was no evidence of any actions taken to address the problem in QMP documentation…
During an interview on 09/01/16 at 4:30 p.m., the Administrator acknowledged the QMP did not encompass all identified agency problems, had minimal tracking and trending of data and did not have performance improvement plans in place for all identified problems."
Chapter II, section 3.1 requires that agencies have a method for taking action to address identified problems, following-up with corrections and evaluating to ensure corrections are effective. Simply identifying a problem is inadequate. Once a problem is identified, the agency needs to address the problem. There is generally not one single solution and the agency will need to implement several things in order to fix the problem. Monitoring will need to occur once corrective measures are initiated to ensure effectiveness. Each agency needs to devise corrective actions that best suit all of the circumstances of the problems initially identified.
To comply with the requirement for documenting the actions taken to address problems or risks, some agencies create one or two page improvement project tools to guide them. The tools include prompts to document at least the following: 1) documentation of the identified problem, 2) planned corrective action to be taken, 3) and the follow-up that took place to ensure the corrective action was successful.
  • Scenario: Agencies treat all issues as isolated events.
Review of agency chart audit documentation revealed that discrepancies were found between what was assigned on care plans and what was documented as provided on service documentation. The quality assurance staff contacted each staff member who had documented the provision of unassigned services and had counseled them individually – in some instances more than once, yet the problem persisted. Interview and record review showed the agency had not tracked and trended chart audit data and the follow-up by quality assurance staff in order to identify a pattern of repeated and systemic problems. As a result, agency-wide corrective measures were not initiated when needed.
Excerpt of a deficiency list
During an interview at 11:00 a.m. on 07/27/16, the agency's PCP Supervisor (Employee #2) stated that s/he had begun review of 100% of the agency's charts using a new chart audit tool in February of 2016. The PCP Supervisor further stated the results of the chart review had not been tallied or summarized.  Instead, discrepancies found between the documentation of timesheets and the care plans were discussed and corrected with PCPs on an individual basis…Although the agency supervisor felt PCP documentation was improving, s/he acknowledged that without keeping track of the type and number of PCP documentation errors, and without keeping track of problems revealed by consumers during supervisory visits, it was not possible to identify trends or evaluate the effectiveness of the agency's efforts in correcting identified consumer related problems.
Chapter II, section 3.1 requires agencies to have a method of investigating and analyzing the frequency and causes of individual problems and patterns of problems. While an agency should act to correct individual problems, the agency should also keep track of these to monitor for recurring problems and consider corrective actions that are broader than one on one counseling.
Some agency administrators require their quality assurance, quality management, and other supervisory staff to track the problems they identify in addition to any individual follow-up and/or staff feedback they provide. Chart auditing findings are not just noted on individual consumer chart auditing tools, but are also logged on an agency-wide tracking sheet that tallies the chart audit findings. With data from each chart audit, an agency-wide tracking sheet helps to highlight trending in problem areas that may not otherwise be identified.
  • Scenario: Agencies track and trend information as their quality management plan directs. However, they do nothing with the information they gather.
An agency routinely conducts satisfaction surveys with their consumers. Every three months a portion of their consumer population was called and a series of questions were asked to assess overall satisfaction with agency services. A lot of useful information from consumer complaints, feedback and suggestions was gathered, however, the agency did not evaluate for patterns of like concerns and corrective measures that should have been taken for clear patterns of problems did not occur. Interviews with agency personnel showed they had not been instructed to share the data they collected and showed they were tracking consumer satisfaction results just for the sake of tracking. (This same type of failure often occurs with the tracking of incidents of falls as well)  

Excerpt of a deficiency list

… Review of consumer clinical records showed the agency conducted satisfaction surveys in addition to the supervisory visits every three months, however, there was no further documentation of what was done with the information gathered from the activities.  Additionally, information from the complaint and occurrence log was not incorporated into the agency's QMP.
The ways in which trends may be identified should be clearly set forth in the agency’s quality management plan and should include data from supervisory visits, complaint tracking, chart audits, etc. This centralized tracking should include information that is gathered and reported by field supervisors inclusive of their observations, the results of the supervisory visits, consumer feedback and any service concerns that have been identified. The agency’s policy should also require staff to routinely report tracked data to quality management personnel. After evaluating the data, the quality management personnel should document the steps in the plan to address the problems, along with implementation and follow-up.
Staff should be held accountable for contributing to these processes by including the agency’s reporting expectations in their job descriptions, informing them of these processes at time of their initial orientation and by providing ongoing training.