Failure to Implement Ongoing QAPI Processes for Resident Grievances
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) process as required by policy. Although the facility's QAPI policy outlined the need to develop, implement, and monitor performance indicators using data from multiple sources, including grievance logs, the actual practice did not align with these requirements. Record reviews showed that grievances filed by residents regarding personal care, bathing, and appearance were not consistently reviewed during QAPI meetings, and no process improvement plans were developed in response to these grievances. Interviews with the Facility Administrator confirmed that while grievances were recognized as a source for process improvements, the facility did not have any active process improvement plans at the time of the survey. Additionally, there was a discrepancy between the number of grievances documented in the grievance logs and those discussed in QAPI meetings, indicating a lack of systematic review and follow-up. This failure to follow QAPI processes had the potential to affect all residents in the facility, with a census of 38 at the time of the survey.