Failure to Implement and Maintain Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required. Although a QAPI policy was in place, review of records and staff interviews revealed that the program was not operational from June 2024 until February 2025 following a change in ownership. During this period, there were no QAPI meeting minutes or documented projects, and key quality programs such as Infection Control and Antibiotic Stewardship were not being implemented. The Administrator and Director of Nursing both confirmed that these programs were not in place prior to their recent arrival and that the QAPI program had only recently been re-initiated. Further review of new employee records showed multiple deficiencies in staff onboarding and compliance with regulatory requirements. Several new hires lacked required dementia training, CNA registry checks, preemployment physicals, tuberculin testing, and documentation of COVID vaccination or declination. The Director of Nursing's license was not checked prior to employment. The Medical Director also confirmed the absence of an Infection Control Program and stated that infection monitoring, antibiotic stewardship, and vaccination tracking were not being conducted or reported to the QAPI committee. These findings demonstrate a lack of comprehensive, data-driven quality assurance processes and oversight during the identified period.