Failure to Maintain Effective QAPI Program and Address Supply Shortages
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting required quarterly Quality Assessment and Assurance (QAA) committee meetings for three consecutive quarters. When a QAPI meeting was eventually held, the team did not address ongoing supply concerns, such as linen and colostomy bag shortages. The QAPI plan in use was outdated, containing indicators and measures only up to the previous year, with no current performance improvement projects or measures for the present year. The absence of an administrator was cited as a reason for the lack of QAA meetings, and there was confusion among leadership regarding oversight and responsibility for the QAPI process. Additionally, there was no established system for obtaining or incorporating feedback from direct care staff and residents into the QAPI process. Reports from staff and residents about shortages affecting care, such as missed showers due to lack of linens and colostomy bags, were not systematically reviewed or addressed in QAPI meetings. Documentation from the most recent QAPI meeting did not include discussion of these ongoing concerns, and leadership was unable to describe how such feedback would be used to identify or resolve problems.