Medical Director's Inconsistent Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee included the Medical Director's participation in at least four quarterly meetings as required. Specifically, the Medical Director did not attend two out of the four required quarterly meetings. The facility's policy mandates that the QAPI committee must include the Medical Director, among other key personnel, and meet at least quarterly. However, the review of attendance sheets revealed that the Medical Director did not sign in for several meetings throughout the year, and there was no documented evidence of their attendance via Microsoft Teams or in person for two of the quarterly meetings. Interviews conducted during the survey revealed discrepancies in the Medical Director's attendance. The Medical Director claimed to attend meetings monthly, often via Microsoft Teams, and stated that a Clinical Assistant would attend in their place if they were unavailable. However, the Clinical Assistant, who primarily performs administrative tasks and is not deeply familiar with the facility's policies, confirmed that they occasionally attended meetings on behalf of the Medical Director. The Administrator corroborated that the Medical Director was invited to meetings via email and that the meetings were accessible in person, by phone, or via Microsoft Teams. Despite these arrangements, the lack of consistent attendance by the Medical Director at the required quarterly meetings led to the deficiency citation.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 F 868 483.75 QAA Committee SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The Medical Director received an Inservice from the Administrator on Regulation Compliance and the importance of attendance at Quality Assurance Committee Meetings. The Medical Director will attend facility QAPI meetings minimally once every quarter. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. The facility reviewed the Quality Assurance Policy and Procedures to ensure regulation compliance. No revision is needed. The Medical Director/ Designee will meet with Quality Assurance Performance Committee at least quarterly to coordinate and evaluate activities such as identifying issues with respect to quality assessment and assurance activities. The Medical Director is required to attend the meeting in person to foster effective communication, collaboration, and engagement with the quality improvement team. If unable to attend in person, the Medical Director/ Designee will attend via TEAMS or Telephonically. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Medical Director / Designee will audit the attendance at Quality Assurance Meeting to ensure compliance of minimally quarterly attendance. The Audit will occur monthly for one year. The Medical Director will be responsible for reporting key data metrics during each meeting. In order to ensure an appropriate quality review for 2024 related to this deficient practice, the Medical Director will review all reports that were presented in the 2024 QAPI meetings. This will develop an understanding of Quality in 2024 in order to continue to improve for 2025 and thereby enhancing quality care for residents at this facility. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Medical Director/ Designee will report findings monthly to the Quality Assurance Committee on the compliance with the regulation for one year. Attendance, along with these reports, will be documented by the Medical Director and provided to the quality improvement coordinator. A log of attendance will be maintained by the administrator. Non-compliance will be reviewed and addressed during performance evaluations with the organization’s Medical Director. Responsible: The Medical Director/ Administrator, organization’s Medical Director are responsible for audit compliance.