Failure to Provide Mandatory QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that all direct care staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. During the survey, the surveyor requested documentation of QAPI training for five randomly selected direct care staff members, including an LPN, an RN, and three CNAs. The Director of Nursing (DON) stated that the facility uses Relias, an online training platform, for staff education and provided training transcripts for the selected staff. Upon review, none of the five staff members had documentation of QAPI training, either as new hires or as part of annual training. Further review of the facility's annual training plan revealed that QAPI training was not included among the mandatory training modules assigned to staff. The Nursing Home Administrator (NHA) confirmed that while there was a procedure for registering employees in Relias and assigning annual training modules, there was no formal education policy or documentation indicating that QAPI training was provided. The lack of QAPI training documentation affected all 108 residents in the facility, as all staff are required to be trained in QAPI to ensure quality care.