Failure to Develop and Implement Required Performance Improvement Project
Penalty
Summary
The facility failed to develop and implement at least one Performance Improvement Project (PIP) within the past year, as required. During interviews, the Interim Executive Director (IED), Director of Nursing (DON), and Lead Administrator of Nevada (LAN) confirmed that while monthly Quality Assurance Performance Improvement (QAPI) committee meetings were held, they were unable to provide documentation or describe any PIP completed in the last year. The LAN explained that the facility's electronic system for documenting PIPs became inaccessible after the former Administrator left, leaving the QAA committee without access to necessary records. The IED, who had only recently assumed the role, was unable to confirm the existence of any current PIPs or locate related documentation. Additionally, the QAPI committee had not been informed of the facility's failure to follow policies and regulations regarding the reporting of abuse, neglect, mistreatment, misappropriation of property, and exploitation. The facility's QAPI Plan indicated that PIPs should be evaluated on an ongoing basis by the QAA committee, but there was no evidence that this process had occurred in the past year.