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F0865
F

Failure to Implement and Maintain QAPI Program

Hancock, Michigan Survey Completed on 07-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop, implement, and maintain an effective and comprehensive Quality Assurance Performance Improvement (QAPI) program that addresses the full range of services provided. During interviews, the DON stated that during a recent QAPI meeting, no topics were discussed as the full team was not present, with both the NHA and IP absent. The NHA reported that the DON supervised the QAPI program, while the DON admitted that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess problems, and had no action plans or ongoing QAPI activities. There was also no feedback, analysis, or tracking for the QAPI program, and the DON expressed a lack of understanding regarding the purpose of QAPI. Review of the facility's policy confirmed the requirement for a data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.

See complete original report
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