Lack of Documented QAPI Activities and Performance Improvement Plans
Penalty
Summary
The facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement (QAPI) program for calendar year 2025, affecting all 94 residents. Review of the facility’s written QAPI plan showed it described principles such as making resident care decisions based on data, setting performance goals, measuring progress toward those goals, and using collected quality improvement data to guide daily operations. However, when surveyors reviewed the QAPI committee meeting minutes from January through December 2025, the documents only contained signatures of interdisciplinary staff in attendance each month and lacked any documentation of topics discussed, identified concerns, data tracking, or measures taken or planned to address concerns in the form of Performance Improvement Plans (PIPs). During an interview, the Administrator stated that the QAPI committee met monthly and that meetings were conducted in person while using a computer-based documenting system, but formal meeting minutes were not taken and concerns were discussed verbally. The Administrator was unable to provide any documentation from the computer-based system or other sources showing identified concerns, data tracking, goals, or ongoing PIPs for 2025. The Administrator further acknowledged that there were no formal ongoing PIPs in place during the previous calendar year or at the time of the interview, despite the facility’s written QAPI policy outlining the expectation for systematic identification, reporting, investigation, analysis, and prevention of adverse events and the development, implementation, and evaluation of corrective actions.
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