Failure to Implement and Document Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program and plan. During an interview and record review, the Administrator acknowledged that the facility did not have appropriate monitoring and documentation for the QAPI program. The QAPI program binder was reviewed and found to lack detail, follow-up, and documentation. Although the QAPI team reportedly performed work behind the scenes, there was no documentation available to show the results of their monitoring activities. The Administrator confirmed that the absence of a well-documented QAPI program and plan meant that quality of care issues may not have been reviewed and correction plans may not have been developed or implemented. A review of the facility's undated policy and procedure for the QAPI program indicated that the Administrator is ultimately responsible for the program and for interpreting its results to the governing body, and that the governing body is responsible for ensuring the program is implemented, maintained, and sustained. However, the facility was unable to provide evidence of ongoing QAPI activities or documentation to support that the program was being followed as required.