Failure of Governing Body to Oversee and Implement Effective QAPI Program
Penalty
Summary
The facility's governing body and executive leadership failed to ensure that the Quality Assurance Performance Improvement (QAPI) program effectively identified and prioritized problems related to organizational processes, functions, and services provided to residents. During the recertification survey, it was found that the QAPI plan lacked a systematic approach for identifying, tracking, investigating, and analyzing data. The Director of Nursing (DON) confirmed that there was no oversight of the QAPI processes by the governing body. Additionally, the Administrator stated that the Chief Financial Officer (CFO) provided oversight, but could not confirm the CFO's participation or input in QAPI meetings. Further interviews revealed that the CFO was only kept informed about the QAPI process by the Administrator and DON and occasionally attended morning calls. The CFO was unable to provide details about the most recent QAPI meeting and had not reviewed the QAPI documentation. When asked about specific issues identified by the QAPI committee, such as nursing staff lacking CPR certification, the CFO was unaware of these findings. These actions and inactions demonstrate a lack of effective oversight and engagement by the facility's leadership in the QAPI process.