Failure to Provide Required QAPI Training to Staff
Penalty
Summary
Facility staff failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to two staff members, a registered nurse and a dietary staff member, as identified through staff interviews and review of facility documents. When education records for these staff members were requested, administrative staff indicated that the facility's recent change in ownership and lack of access to previous personnel records prevented them from providing the required documentation. The assistant director of clinical services, who was new to the role, was unable to explain why the required trainings had not been completed in the past. A review of the facility's policy on in-service training revealed that employees are to receive training on required topics annually, with additional training as needed based on facility assessment and regulatory requirements. The policy also states that each center is responsible for ensuring compliance with federal, state, and local training regulations. No further information or documentation regarding the missing QAPI training was provided to the survey team prior to their exit.