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MILLE LACS HEALTH SYSTEM
QAPI
Tag No.: C1306
Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure all departments CAH wide were evaluated through the quality assessment and performance improvement (QAPI) program.
Findings include:
On 3/25/25, a review of QAPI documents lacked evidence of a QAPI project for discharge planning and telemedicine.
During an interview on 3/25/25 at 4:10 p.m., Director of Quality (DQ) indicated there was no QAPI projects for discharge planning and telemedicine. DQ stated there was nothing formal reported to the QAPI committee.
The facility policy Quality Assessment and Performance Improvement (QAPI) Program, undated revealed the facility would complete an annual Program Assessment would be completed as part of the QAPI program. The assessment would look at an annual summary of the dimension of care within our services and the evaluation of utilization from the previous year. In addition, the QAPI activities would be integrated across all service areas of their facility.