Failure to Maintain and Document QAPI Program Activities
Penalty
Summary
The facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104 residents. During interviews, multiple staff members, including the Director of Staff Development, Social Services Director, Infection Preventionist, and Minimum Data Set Manager, were either unaware of or unable to provide documentation for the previous three quarterly QAPI meetings. The Administrator confirmed that there were no records of QAPI meetings for the last three quarters and acknowledged that QAPI meetings had not been conducted prior to their arrival. The facility's policy requires maintaining documentation and evidence of ongoing QAPI activities, but this was not followed. Record review and staff interviews revealed that the facility did not maintain documentation or present evidence of QAPI meetings as required. The lack of documentation and awareness among staff indicated that QAPI activities were not being consistently performed or tracked. The Minimum Data Set Manager noted ongoing issues with resident rehospitalization rates, suggesting that performance improvement activities were not being effectively evaluated or revised. The absence of QAPI meeting records and lack of staff knowledge about the process contributed directly to the deficiency.