Medical Director's Absence in 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 or their designee in quarterly meetings, as required by their policy. The facility's QAPI policy, last revised in 2022, mandates that the committee must consist of the director of nursing services, the medical director or designee, and at least one other member of the facility staff, with meetings held quarterly. However, a review of the Quarterly Meeting Attendance Sheets revealed that the Medical Director did not sign the attendance sheets for any of the four quarterly meetings in 2024, indicating a lack of participation. Interviews conducted during the survey revealed discrepancies in the Medical Director's involvement. The Director of Nursing stated that the Medical Director only attends quarterly meetings, while the Medical Director claimed to attend some meetings and be informed by the Administrator about the discussions. The Administrator confirmed that the Medical Director does not physically attend the quality assurance meetings but is briefed afterward. This lack of documented attendance and participation by the Medical Director in the QAPI and QAA meetings constitutes a deficiency in meeting the facility's policy requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò The Medical Director was in-serviced on 2/13/25 on the requirement to attend the QAPI meetings quarterly or designate a qualified representative in their absence. ò The Medical Director was instructed to sign the attendance sheet for all QAPI meetings to ensure proper documentation of participation on 2/13/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? ò The facility Policy and Procedure was titled QAPI, was reviewed and dated, no revision needed. ò An Audit tool is being developed to monitor the attendance of all QAPI committee members. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a quarterly basis for the one quarter, the Administrator, or designee, will monitor the attendance of all QAPI committee members to ensure compliance. ò Quarterly, the Administrator or designee will formally invite the Medical Director to the QAPI meetings. ò Quarterly for on the Administrator or designee will ensure the Medical Director attends each quarterly QAPI meeting, either in person or via Zoom. ò The Administrator or designee will verify and document the Medical Director’s attendance at each QAPI meeting. 5. The title of the person responsible for correction of each deficiency: Administrator