Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its staff, as required. During the survey, the administrator was unable to produce any documentation showing that QAPI training had been conducted for staff in 2024 or 2025. The in-service binders provided did not contain any evidence of QAPI-related training, and both the administrator and nurse consultant confirmed that no such documentation existed. The nurse consultant and assistant director of nursing also searched the director of nursing's office for additional records but found none. Furthermore, there was no training schedule for required in-services, and the facility assessment did not identify a need for QAPI training. Interviews with facility leadership revealed that direct care staff were not trained on QAPI and would not know how to submit concerns directly to the QAPI committee, as the established process was to report issues to supervisors. The nurse consultant acknowledged that direct care staff should be involved in QAPI processes, as they are integral to identifying and driving needed changes. The lack of QAPI training documentation and absence of a training schedule affected all 93 residents in the facility, as staff were not adequately prepared to participate in or contribute to the facility's QAPI program.