Failure to Implement Facility-Wide QAPI Program with Active PIP
Penalty
Summary
The facility failed to develop and implement an ongoing, facility-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program that included at least one current Performance Improvement Project (PIP) within the past 12 months. Upon review, the facility provided its QAPI policy, which outlined the process for identifying areas for improvement, including high-risk, high-volume, and problem-prone areas, and emphasized the importance of considering the incidence, prevalence, and severity of problems affecting resident outcomes. However, during an interview, the Nursing Home Administrator (NHA) confirmed that no PIP had been identified or implemented in the last year. Further review of the QAPI committee's documentation revealed that while meeting minutes and highlights of high-risk topics such as falls, wounds, and maintenance concerns were maintained, there was no evidence of a structured approach to systematically identify and address quality issues. The NHA stated that QAPI meetings primarily served as notification forums, and daily clinical meetings were used to review clinical concerns and interventions. No documentation was provided to demonstrate that the facility was systematically investigating root causes, implementing interventions, or monitoring the effectiveness of corrective actions as required by their own policy.