Failure to Implement Data-Driven QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) Committee developed, implemented, and maintained a comprehensive Quality Assurance Performance Improvement (QAPI) program. The QAPI policy required the use of data-driven analysis, benchmarking, and measurable goals for improvement, but these elements were not present in the facility's actual practices. The Administrator, who was responsible for QAPI, initiated a project to improve the grievance process but did not use data or benchmarks to establish a starting point or measure improvement, relying instead on subjective impressions of increased understanding and usage of the process. The Administrator also acknowledged missing a recent grievance, which was brought to attention by surveyors. The Director of Nursing (DON) was working on a project to improve completion of resident incident reports but did not know the baseline data or use metrics to track progress. The DON stated that the goal was 100% completion but had no data to determine the current status or to measure periodic improvement. Both the Administrator and DON admitted to lacking training on QAPI processes, including the use of systematic methods such as Plan-Do-Study-Act cycles, and were unaware of the tools available for managing and sustaining improvement. They described their approach as identifying a problem, providing education, and monitoring until a goal was met, without seeking feedback from line staff or ensuring sustainability of changes. The Director of Operations confirmed that the facility leadership was expected to use data-based evidence and metrics, including root cause analysis and measurable goals, to sustain improvements. However, based on the information provided, the Director of Operations acknowledged that the required processes for QAA and improvement projects were not in place as required by organizational policy. The deficiency was identified through interviews and review of facility practices, which did not align with the written QAPI policy.