Failure to Provide Documented QAPI Training to All Staff
Penalty
Summary
Facility staff failed to provide mandatory training to all staff on the elements and goals of the facility’s Quality Assurance and Performance Improvement (QAPI) program. During a review of the facility’s education and training records, surveyors found only a list of training topics and sign-in sheets for a skills fair, with no documented evidence that QAPI training materials or a review were actually provided to staff. Additionally, there was no documentation to show that staff who did not attend the skills fair received QAPI training. The facility’s educators were unavailable to clarify the records or provide further information regarding the training. Interviews with facility leadership confirmed that all staff are required to receive QAPI training, typically during orientation and annual skills fairs. However, upon review, the Regional Director of Operations and the Administrator were unable to substantiate that comprehensive QAPI training had been delivered, or that staff were informed about how to communicate concerns or opportunities for improvement to the Quality Assessment and Assurance (QAA) Committee. The Administrator acknowledged that staff education on QAPI was insufficient and that recent training efforts had been limited, with the new educator only providing remote sessions.