Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to all staff, as required by its own policy. Record reviews showed that five certified nurse assistants did not have evidence of receiving QAPI training, which should have included education on QAPI principles, staff roles, communication with the program, and participation in performance improvement projects. The facility's policy specified that all staff, including contracted staff, must be educated on QAPI during orientation and annually, but this requirement was not met for the employees reviewed. The Administrator and Regional Director of Operations confirmed the lack of documentation for this mandatory training during an interview with the surveyor.