Failure to Ensure DON Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services attended the quarterly Quality Assurance Process Improvement (QAPI) committee meetings for nine consecutive months, from February 2024 through October 2024. This was determined based on a review of the QAPI committee meeting attendees list, which consistently lacked the presence of the Director of Nursing. The absence of the Director of Nursing was confirmed by the facility's Regional Staff during a meeting on January 15, 2025. Additionally, there was no sign-in sheet or meeting minutes available for July 2024 to confirm the attendance of any required members at the QAPI meeting. The facility did not provide this documentation at the time of the survey, and a request for copies of the original QAPI sign-in sheet was not fulfilled. This lack of documentation and attendance by the Director of Nursing constitutes a deficiency in meeting the regulatory requirements for the facility's Quality Assessment and Assurance committee.
Plan Of Correction
1) QAPI meeting has been held with appropriate attendees signatures obtained. 2) Past 3 months QAPI will reviewed to determine appropriate staff members that were missing. The NHA / designee will review the past three months of QAPI meeting minutes with the Director of Nursing. 3) NHA and Director of nursing will be educated by the Regional Clinical Consultant / Designee on Facility QAPI policy and ensuring appropriate staff members present. 4) Monthly QAPI will be audited for three months for appropriate staff member attendance. Variances will be addressed and reported to the QAA Committee.