Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for ten staff members, as required by §483.95(d). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, "In-Service Training, All Staff," which was last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care, including the elements and goals of the facility's QAPI program. However, documentation revealed that none of the ten staff members, including nurse aides, registered nurses, a medical records employee, a therapy employee, and a dietary employee, received the required QAPI training within the specified timeframes. During an interview, the Nursing Home Administrator confirmed the lack of QAPI training for these staff members. The staff members had various hire dates ranging from 1995 to 2023, and the failure to provide QAPI training occurred between 2023 and 2025, depending on each employee's hire date. This oversight indicates a systemic issue in ensuring compliance with mandatory training requirements, as outlined in the facility's policy and federal regulations.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with QAPI training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0944 was not uploaded to the training platform. QAPI training has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0944 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.