Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training and education to all staff regarding the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program. According to the facility's own policy, small group education sessions on QAPI are to be provided to all caregivers, and QAPI is included in orientation for new staff. The administrator is responsible for ensuring ongoing orientation, education, and training on QAPI, and staff are expected to answer questions about performance improvement during annual evaluations. However, a review of five staff education records, including those of two nurses, a unit manager, a social worker, and the staff development coordinator, showed no evidence that QAPI training had been completed for any of them. Interviews with these staff members confirmed the lack of QAPI training. One nurse was unfamiliar with the QAPI program and its goals, and stated she had not received any training. The unit manager attended QAPI meetings but could not recall any related education or in-servicing. The social worker reported that her online training and orientation did not include QAPI information. Another nurse also stated he had not received any QAPI training or orientation. The staff development coordinator, who recently attended orientation, did not recall any QAPI training and noted that while there may have been a slide about QAPI in the orientation presentation, she could not recall any details and did not review QAPI with staff during orientation.