Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual training on its Quality Assurance and Performance Improvement (QAPI) program to five employees, including a housekeeper, a certified nursing assistant (CNA), a dietary aide, a certified medication aide (CMA), and a registered nurse (RN). Review of personnel records for these staff members showed no evidence of QAPI training being completed within the previous 12 months. The HR Coordinator confirmed that while monthly in-service trainings were conducted on various topics, QAPI training was not documented as being provided annually to these employees. The facility's policy requires annual education on the QAPI program, but this was not followed for the staff in question. Interviews with the HR Coordinator, DON, and Administrator revealed that the process for delivering in-service trainings involved the HR Coordinator preparing materials and department heads presenting them to their staff, with the HR Coordinator responsible for verifying completion. Despite this process, the required QAPI training was not completed or documented for the identified staff members. The lack of annual QAPI training was acknowledged by facility leadership as a gap that could leave staff uninformed about essential quality assurance practices.