Failure to Develop and Document Effective QAPI Program for Infection Control
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) team developed and revised a quality improvement program to address infection control concerns identified through tracking and trending, as well as the infection control process presented by the DON during routine QAPI meetings. Review of QAPI meeting attendance rosters and minutes revealed a lack of documentation regarding the program's focus, benchmarks, goals, or current Performance Improvement Plan (PIP) initiatives. Handwritten notes from a meeting referenced infection control but did not provide context or identify patterns of infection, despite noting staff illness and COVID-19 cases. Subsequent meeting records were incomplete, with gaps in documentation and minimal information on infection control activities or action plans. During an interview, the administrator reported being unable to locate any program-specific information about the QAPI program or PIP initiatives prior to her recent arrival. She stated that the facility was only beginning to formalize the QAPI program and develop a PIP, with plans to use current survey results to identify focus areas. The facility's QAPI policy indicated that the program should be ongoing and comprehensive, but the documentation and interviews demonstrated that these requirements were not being met, potentially affecting all 28 residents in the facility.