Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to nine out of ten reviewed staff members. Review of the facility's policy indicated that all new and existing staff are required to receive training on several topics, including the elements and goals of the QAPI program. Examination of training records and personnel files revealed that staff members from various departments, including nurse aides, an occupational therapist, a registered nurse, laundry, housekeeping, and dietary, did not have documented QAPI in-service education within the required annual period. This lack of documentation was confirmed through review of training records and staff interviews. The deficiency was further substantiated during an interview with the Nursing Home Administrator, who acknowledged that the required QAPI training had not been provided to the majority of staff reviewed. The absence of this training was found to be in violation of the facility's own policy and state regulations regarding staff development and management responsibilities. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.