Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) to eight out of nine staff members, as required by §483.95(d). The deficiency was identified through a review of facility personnel in-service training records and staff interviews. The staff members who did not receive the required QAPI training included Nurse Aides, a Central Supply Employee, an Activities Assistant, a Registered Nurse, and a Licensed Practical Nurse. Each of these employees had specific hire dates, and the records showed that they did not receive QAPI in-service education within the required timeframe after their hire dates. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the necessary QAPI training to these staff members. This lack of training was in violation of the regulatory requirements set forth by the facility's QAPI program, as well as state codes related to the responsibility of the licensee, management, and staff development.
Plan Of Correction
1. The facility will ensure employees receive QAPI training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives QAPI training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.