Failure to Implement and Document QAPI Program and Event Reporting
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of an ongoing QAPI program that meets regulatory requirements. Staff interviews revealed that there was no QAPI plan in place at the time of the survey, and staff were still in the process of implementing one. Data collection was reportedly occurring through risk management, chart review, and infection prevention binders, but there was a lack of systematic identification, reporting, investigation, analysis, and prevention of adverse events. Staff also indicated that regular care conferences with residents or their representatives were not being held, which limited the gathering and presentation of feedback to the QAPI committee for identifying quality-of-care concerns. Review of facility documents showed that while some QAPI meetings were held and incidents such as falls and urinary tract infections were noted, there was no documentation of tracking, root cause analysis, or performance improvement projects (PIPs) being initiated when indicated. Additionally, the facility had not submitted any facility-reported incidents to the State Survey Agency and could not provide completed investigations for any reportable events. The administrator, who was also serving in multiple roles, acknowledged not documenting incidents or investigations and was unaware of issues requiring reporting. The QAPI program and performance plans did not show active identification or correction of concerns related to event reporting or follow-up.