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QAPI Submission

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When filling out the QAPI form, please note Corrective Action will be automatically completed by Coda’s AI. If the suggested Corrective Action is not suitable, please correct it in the form OR we can discuss alternatives during QAPI meeting.

Form
2
Author
(and/or) Email
Submission Date
*
Department
*
Issue
*
Findings
*
Frequency of Monitoring
*
Duration
*
Follow-up Date
*
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Previously Submitted QAPI Forms
2
(and/or) Email
Issue
Several patients have complained that the handrails are loose on the 2nd floor hallway.
Findings
Several sections of the hallways have loose handrails
Corrective Action
Frequency of Monitoring
Monthly
Duration
One year
Follow-up Date
7/14/2024
Department
Housekeeping
(and/or) Email
Issue
Several patients on the third floor are complaining about the quality of their food and lack of variety.
Findings
Determined that for three weeks in a row, patients were served chicken nuggets five days a week. The breakfast menu has not changed for several weeks
Corrective Action
Frequency of Monitoring
Once a week
Duration
Four months
Follow-up Date
11/14/2023
Department
Social Work
(and/or) Email
Billy@billy.com
Issue
Complaints about other roommate
Findings
John Smith is not happy and often takes it out on his roommate
Corrective Action
Frequency of Monitoring
1 month
Duration
3 month
Follow-up Date
7/16/2023
Department
Social Work
Kenneth R
Issue
Patient is not happy with his roommate and often complains about the noise his roommate makes while sleeping
Findings
John Smith’s roommate is Jacob Alen and has sleep apnea
Corrective Action
Frequency of Monitoring
once daily
Duration
3 months
Follow-up Date
10/16/2023
Department
Social Work
(and/or) Email
Issue
Received complaints that patients are not able to collect cash during banking hours
Findings
Determined that the banking hours by the finance office conflicts with activity’s event hours. Additionally, patient Jacob Smith did not have enough funds to cover his request therefor no funds could be provided.
Corrective Action
Frequency of Monitoring
Once a week
Duration
One month
Follow-up Date
8/17/2023
Department
Finance
Kenneth R
Issue
Human Resources was advised that an agency employee was terminated. Therefore, CHRC for this employee was also terminated. However, the termination was rescinded and Human Resources was not notified of the reinstatement of employee. Therefore, it was found that the employee continued to work without having fingerprints on file.
Findings
One employee was found to be working without current fingerprints. When discovered, the employee was immediately removed from the schedule.
Corrective Action
An education will be held with all involved regarding the importance of employees being scheduled to work without prints or reinstated after having been terminated. An audit will be done monthly for the next six months to ensure no one is working without proper fingerprints on file. Only Administrator, Assistant Administrator, Directors, Assistant Directors Human Resources, and Staffing Coordinator can terminate an employee. Human Resources must be informed of all terminations, hires, reinstatements immediately.
Frequency of Monitoring
Monthly
Duration
Six months
Follow-up Date
12/29/2023
Department
Administration
Kenneth R
Issue
There are a lot of falls happening in the building
Findings
15 falls in the past month
Corrective Action
Implement safety measures such as adding handrails, non-slip mats, and proper lighting to prevent falls in the building. Conduct regular inspections and maintenance to ensure these measures are effective.
Frequency of Monitoring
Daily
Duration
Permanent
Follow-up Date
7/15/2023
Department
Nursing
Kenneth R
Issue
15 residents have reported inadequate supplies in the recreation room such as missing paints, not enough notebooks, not enough large print crossword puzzles, etc.
Findings
It has been determined that there is a lack of supplies due to the lack of funding.
Corrective Action
Allocate additional funding for the recreation room to ensure that all necessary supplies are available for residents to use.
Frequency of Monitoring
Once
Duration
Three months
Follow-up Date
8/15/2023
Department
Activities
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