Failure to Ensure Staff Completion of Mandatory QAPI Training
Penalty
Fine: $126,019
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 ensure that all staff completed mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. A review of employee Human Resources files and the Education Tracking spreadsheet revealed that there was no evidence of QAPI training for nine out of ten sampled permanent and contracted direct care staff, including both LNAs and LPNs. During an interview, the Administrator confirmed that the reviewed employee files contained the only available documentation for staff training and competencies, and was unable to provide evidence that the required QAPI training had been completed by the identified staff members.