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QAPI Submission

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

Form

Author

(and/or) Email

Submission Date

Department

Issue

Findings

Frequency of Monitoring

Duration

Follow-up Date

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Previously Submitted QAPI Forms

Previously Submitted QAPI Forms

(and/or) Email

Jenkins@gmail.com

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

Tighten all loose handrails in the identified sections of the 2nd floor hallway.

Conduct regular checks of all handrails in the facility to ensure they are secure and stable.

Frequency of Monitoring

Monthly

Duration

One year

Follow-up Date

7/14/2024

Department

Housekeeping

(and/or) Email

Ken@Kenneth.com

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

Provide a wider variety of food options for patients on the third floor.

Ensure that the menu is changed frequently to prevent repetition and boredom with food choices.

Conduct regular surveys to gather feedback from patients about their satisfaction with the food and make necessary changes based on their feedback.

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

Hold a meeting with John Smith and his roommate to address the complaints and find solutions to the issues.

Provide counseling services to John Smith to address any underlying mental health concerns that may be contributing to his behavior.

If necessary, consider relocating John Smith to a different living arrangement to ensure the safety and well-being of all residents involved.

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

Recommend that John Smith speak with his roommate Jacob Alen about the noise issue and explore potential solutions.

Suggest that John Smith consider requesting a room change if the issue cannot be resolved through communication with the roommate.

Offer to connect John Smith with resources or support services to address any related emotional or mental health concerns he may have.

Frequency of Monitoring

once daily

Duration

3 months

Follow-up Date

10/16/2023

Department

Social Work

(and/or) Email

Michael@Michael.com

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

Adjust finance office banking hours to avoid conflicts with activity event hours.

Review patient account balances prior to scheduling cash requests to ensure adequate funds are available.

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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