Failure to Implement QAPI Program and Conduct Required PIPs
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan and program as required. Specifically, the facility did not conduct at least one performance improvement project (PIP) annually, which is a requirement outlined in their QAPI plan. During an interview, the DON stated that issues are identified and addressed during morning meetings, typically through in-services or CNA check-offs, rather than through formal PIPs. The ADM, who is responsible for the QAPI program, acknowledged understanding what a PIP is but indicated that no changes were made to the system upon her arrival because she believed the facility was performing well. A review of the facility's QAPI plan confirmed that the facility is expected to conduct PIPs in high risk or problem-prone areas at least annually, based on data collection and analysis. However, the facility did not follow this process, as no PIPs were conducted during the review period. This lack of formalized quality improvement activities was identified through both interviews and record review.