Lack of Documentation and Participation in QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing, effective, and comprehensive Quality Assurance and Performance Improvement (QAPI) program as required. During interviews and record reviews, it was found that the facility did not have documentation demonstrating the development, implementation, or evaluation of a performance improvement activity for the one sampled Process Improvement Project (PIP) reviewed. The facility also could not provide sign-in sheets or proof that the medical director participated in QAPI meetings at least quarterly, as required by policy. The administrator was unable to produce a QAPI plan or evidence of any current or past performance improvement activities when asked. Additionally, the only document provided in response to requests for QAPI documentation was a sparse meeting record that did not contain the relevant information needed to demonstrate compliance. No PIP documentation or sign-in sheets from QAPI meetings were provided, and the administrator acknowledged the lack of these records. The facility's policy requires a data-driven, proactive approach involving all levels of staff, but there was no evidence that these processes were being followed or documented.