Failure to Implement and Document Required PIP for Pain Management
Penalty
Summary
The facility failed to provide evidence of an effective Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, as required by their QAPI program. Review of QAPI meeting minutes from June 2024 through March 2025 showed that although the committee selected pain management as a PIP topic, there was no documentation of data collection, analysis, evaluation of the concern, or development of an action plan throughout this period. The QAPI minutes for each month consistently lacked these essential components, indicating that the PIP process was not followed as outlined in the facility's own QAPI plan. An interview with the administrator confirmed that the QAPI committee had chosen pain management as the PIP project but had not developed an action plan or followed the required steps of the PIP process. The facility's QAPI plan specifies that PIPs should include data collection, root cause analysis, measurable goals, and an action plan, but these steps were not documented or implemented for the pain management project. This deficiency had the potential to affect all 43 residents in the facility.