Failure to Implement and Operate QAPI Program
Penalty
No penalty information released
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 establish priorities for improvement activities, develop and implement action plans, and review or analyze data collected under its Quality Assurance Performance Improvement (QAPI) program. During an interview, the DON stated that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess for problems, and had no action plans or ongoing QAPI activities. The DON also expressed a lack of understanding regarding the purpose of the QAPI program. Review of the facility's policy confirmed that it requires the development and maintenance of a comprehensive, data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.