Failure to Track and Measure QAPI Program Performance
Penalty
Summary
The facility failed to maintain an effective system for tracking and measuring the performance of its Quality Assurance and Performance Improvement (QAPI) program. According to the facility's own QAPI policy, the program should be comprehensive, data-driven, and include processes for tracking and measuring performance, establishing goals and thresholds, and monitoring the effectiveness of corrective actions. However, a review of QAPI meeting minutes for March and April did not show any evidence of tracking QAPI performance or outcomes. The documentation lacked data collection, analysis, or any indication of how performance was being measured or evaluated against set goals. During an interview, the Administrator stated that performance was monitored through morning meetings and that the DON kept track of falls, but was unable to specify what the compliance or target goals were for the issues identified in the QAPI plan. The QAPI minutes included discussions on antipsychotic use, pharmacy issues, maintenance repairs, and falls, but did not document any measurable outcomes or tracking of progress toward resolution. This lack of documentation and measurable tracking constitutes a deficiency in the facility's QAPI program.