Failure to Maintain Documented QAPI Program and Performance Improvement Activities
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with adequate documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Although the facility's QAPI policy outlined a comprehensive process for addressing clinical care, quality measures, and other key areas, document review revealed that the QAPI manual lacked meeting minutes for several months and did not include evidence of corrective actions or monitoring for identified issues. Departmental reports listed potential concerns and activities, but there was no documentation of performance improvement projects (PIPs) being developed, implemented, or evaluated, except for a single mention of a food temperature project without follow-up data or outcomes. Interviews with the Administrator confirmed that while monthly QAPI meetings were reportedly held, there were no written records of discussions, goals, or data analysis for several months. The Administrator also indicated a lack of awareness regarding the requirement for ongoing PIPs. The QAPI manual contained lists of departmental activities and identified concerns, but these lacked details on corrective actions, monitoring, or evaluation of effectiveness, demonstrating a failure to address the full range of care and services, including clinical care, as required by the facility's own policy.