Failure to Complete Required Quality Assurance and Performance Improvement Program
Penalty
No penalty information released
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 complete a Quality Assurance and Performance Improvement Program (PIP) within the past year, as required by its own policy. Upon request, the facility was unable to provide evidence of any PIP completed in the last year. During an interview, an administrative staff member stated that she expected the administrative nurse to complete all PIPs and believed the last PIP was completed approximately one and a half years ago. The facility's policy indicated that PIPs should be developed and maintained to address care and service areas needing attention, based on data-driven indicators and prioritization tools. However, no documentation or evidence of such activities was available for the past year.