Deficiency in QAPI Program for New Hire Employee Files
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the area of new hire employee files. The facility's policy, dated January 11, 2024, aimed to establish a framework for continuous improvement in the quality of care and services. However, during a review of the facility's documentation and interviews with staff, it was found that the facility did not follow a performance improvement project (PIP) for new hire employee files. A new process for new hire employees was initiated on December 13, 2024, but was not effectively implemented. During the review of five employee records, several deficiencies were identified: four out of five professional licenses were not verified for accuracy prior to employment, all five physicals were not completed before employment, all five Tuberculin tests were not conducted, four out of five employee job descriptions were missing, and two out of five background checks were not completed prior to employment. Additionally, a Registered Nurse (RN) was allowed to work despite having an expired and probationary license. The Director of Nursing confirmed that the facility failed to implement an effective QAPI plan for new employees, as the past HR director did not communicate the expired license issue.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. A new process for new hires has been implemented and will be followed for new hires. An audit of new hires for the past 3 months will be completed to ensure all the required paperwork is completed. 3. The Human Resource Director will be reeducated on the new process by the Regional Human Resource Director/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for three weeks and monthly for three months to ensure all required paperwork is completed and the performance improvement plan is followed. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.