Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff members upon hire and did not conduct in-service training on QAPI for direct care staff. Review of the QAPI Binder, which was last revised in April 2023, showed no documentation of QAPI training for staff, despite committee signatures indicating that staff are to be trained in QAPI systems and principles. Additionally, the facility assessment listed monthly in-services on various topics such as disaster drills, abuse/neglect, and resident rights, but did not include QAPI training. Employee file reviews for a CNA and an LPN revealed no evidence of QAPI training at the time of hire, although other required trainings were documented. Interviews with the Administrator and Director of Operations confirmed that QAPI in-services were not conducted and that QAPI meetings were held quarterly with participation from the executive team, but there was no evidence of QAPI training for all staff as required.