Failure to Develop and Implement a Facility-Specific QAPI Plan
Penalty
Summary
The facility failed to ensure that a Quality Assurance Performance Improvement (QAPI) plan was in place, as required by regulations. During an interview, the Administrator acknowledged that there was no specific QAPI plan, and that the facility was relying on its QAPI policy as a substitute. Document review revealed that the existing policy, titled 'Quality Assurance and Performance Improvement Program Committee Guidelines' and last revised in 2019, did not include the necessary elements for a QAPI plan, such as processes for guiding performance improvement efforts, tracking and measuring performance, or identifying and correcting quality deficiencies. Further, the Administrator confirmed that the QAPI plan should be individualized to the facility, including vision, mission, and purpose statements, as well as guiding principles tailored to the specific units, programs, departments, and population served. The lack of a comprehensive and facility-specific QAPI plan was acknowledged by the Administrator, and it was noted that the current policy did not meet the requirements outlined in the state operations manual.