Lack of Measurable Goals and Action Plans for Restorative Program PIP
Penalty
Summary
The facility failed to provide evidence of measurable goals and documentation of analysis and evaluation of data for its Performance Improvement Projects (PIPs), specifically regarding the Restorative Program. Review of QAPI meeting minutes from multiple dates showed that while the Restorative Program was identified as a PIP, there were no measurable goals or action plans discussed or implemented. Meeting records included blank tables labeled for action plans, responsible persons, target dates, outcomes, and notes, but these sections remained unfilled. Summaries provided by the DON included only the number of days of Restorative therapy provided and lists of residents who did not attend therapy, without any documented action plan or measurable goals to address the identified issues. During an interview, the administrator and the social services designee acknowledged the lack of development and documentation of measurable goals and associated action plans for the Restorative Program PIP. The facility's own QAPI policy required quarterly meetings to evaluate and coordinate activities, including PIP projects, with actions to be monitored and documented. However, the documentation reviewed did not show that these requirements were met, and there was no evidence of oversight or a documented action plan for the identified PIP.