Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. Review of personnel files for these employees showed no documentation of QAPI training within the required annual period, as specified by the facility's own policy and federal regulations. The policy mandates that all staff, including those under contract and volunteers, must receive training on the QAPI program prior to independently providing services, annually, and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the required QAPI training was not provided to these staff members. The deficiency was identified through review of training records and personnel files, which lacked evidence of completed QAPI training for the specified period for each of the five staff members. No information about residents or their conditions was included in the report.
Plan Of Correction
Employee's 5, 6, 8, and 9 will receive Quality Assurance and Performance Improvement training in January 2026. All employees will receive an annual Quality Assurance and Performance Improvement training during a set month of the year. The Human Resource Director will educate all Department Directors on the annual education requirements for Quality Assurance and Performance Improvement training. The Human Resource Director or designee will audit the training to assure all staff have been educated on Quality Assurance and Performance Improvement training topics. Audit results will be turned into the Quality Assurance meeting monthly. F 0944