Deficiency in QAPI Training for Staff
Penalty
Summary
The facility failed to meet the requirement for Quality Assurance and Performance Improvement (QAPI) training as outlined in §483.95(d). This deficiency was identified through a review of facility documents, employee education records, and staff interviews. Specifically, five out of seven staff members, including four Nurse Aides (Employees E7, E8, E9, and E11) and one Registered Nurse (Employee E12), did not receive the mandatory QAPI training within the specified time frames. The facility's policy, dated 5/23/24, mandates that all new staff receive training during orientation and annually thereafter. However, the training records revealed that these employees did not have documented QAPI education during their respective annual periods. The Staff Development Coordinator confirmed the lack of training for these staff members during an interview.
Plan Of Correction
All employees with upcoming evaluations will have necessary required in-service education and training, including QAPI, for a total of 12 hours by their evaluation date. Employee training will be monitored, and each employee's status of education completion will be pulled at least each quarter to ensure completion in a timely manner prior to the evaluation date, by the staff development coordinator and Director of Nursing. Education to all nursing staff will be given by Staff Development or designee. QAPI on staff education training compliance will be done weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reported to the QA Committee.