Failure to Implement QAPI Data Collection and Monitoring
Penalty
Summary
The facility failed to utilize its Quality Assurance Performance Improvement (QAPI) program to develop and implement policies and procedures for data collection systems, feedback, monitoring, analysis, and action, including adverse event monitoring. During an interview and record review, the Administrator confirmed that the QAPI program did not include measures for monitoring and documentation, and that these components were not compiled or input into facility records. The facility's QAPI policy indicated that the program should be based on data, resident and staff input, and other information that measures performance, but these processes were not addressed or implemented. As a result, the facility did not collect data or identify corrective measures for any issues affecting the facility.