Lack of Formalized QAPI Plan and Documentation
Penalty
Summary
The facility failed to provide a formalized Quality Assurance and Performance Improvement (QAPI) plan that included necessary policies and procedures for identifying and correcting quality deficiencies. During interviews, the administrator acknowledged that there was no QAPI plan in place to track and measure performance, no established goals, and no evidence of corrective action or performance improvement activities. Although attendance rosters for quarterly QAPI meetings were available, there was no documentation reflecting the QAPI process, and the administrator, who was new to the facility, had not yet implemented such a process. Further review revealed that while the director of nursing (DON) attended quarterly quality assurance meetings and provided updates on infection control and facility status, there was no documentation of QAPI presentations or evidence of any current or previous QAPI programs. The only policy provided was a general QAPI/QAA plan updated earlier in the year, which referenced facility-specific goals and documentation that could not be produced for the current year. This deficiency had the potential to affect all 29 residents in the facility.