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F0867
F

Lack of Formal Performance Improvement Projects in QAPI Program

Hendricks, Minnesota Survey Completed on 04-30-2025

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 provide evidence of an ongoing Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) program. Review of QAPI meeting minutes from April 2024 through March 2025 showed no PIP projects with documented goals, action plans, data collection, or analysis for areas or issues identified as needing improvement. During an interview, the Director of Aging Services, the facility administrator, and the DON confirmed that while there had been some previous PIP projects, no formal PIP plans had been developed in the past year. The facility's QAPI policy requires the identification and correction of high-risk, high-volume, or problem areas, but this process was not followed, potentially affecting all 47 residents in the facility.

See complete original report
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