Medical Director's Absence in QAPI Meetings
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure QAPI meetings were held quarterly. Requested meeting minutes were not fully provided, and the DON stated the January meeting was not held, a planned reschedule did not occur, and fall meeting notes could not be opened or were never resent. The QAPI Plan stated concerns, updates, or changes are to be reviewed at quarterly meetings.
Medical Director Did Not Participate in Quarterly QAA Meetings: The facility failed to ensure the Medical Director took part in quarterly QAA meetings. Record review showed no documentation of the Medical Director attending any QAA program meetings over several months, and both the Administrator and the previous Medical Director confirmed the absence of attendance.
The facility did not maintain a QAA committee with the required members. The policy required the DON, Medical Director, Administrator, at least two other staff members, and the infection control and prevention officer, but the QA/QAPI attendance sheets did not include an IPC at two quarterly meetings. The NHA acknowledged that the IPC does not always attend and should attend the meetings, and the DON stated she was not certified in infection prevention and control.
QAPI committee attendance records showed the facility did not hold a meeting during the first quarter and that the Infection Preventionist did not attend the documented meeting. The NHA confirmed the findings during interview.
Failure to hold required QAA meetings. Review of QAA attendance records showed only one committee meeting in one quarter and one meeting in a later quarter, and the NHA confirmed the facility did not conduct QAA meetings at least quarterly with all required committee members.
QAPI Committee Lacked Required IP Attendance: The facility failed to document that the Infection Preventionist attended QAPI meetings on a quarterly basis. Policies identified infection prevention as part of the QAPI process, but attendance records showed no documented evidence that the IP was present at the meetings, and the Administrator and Regional Administrator stated they knew the requirement but did not know why the IP had not attended.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that QAPI meetings were held on a quarterly basis. Record review and interview showed that the last three QAPI meeting minutes were requested by email, but only the April 6 meeting minutes were provided initially. The remaining two sets of minutes were requested again on multiple occasions, but were not provided. On interview, the DON stated the facility had not conducted its QAPI meeting in January, had planned to reschedule it, but was unable to do so. The DON also stated the facility had met in the fall, but the notes could not be opened, and despite being given the opportunity to resend them or provide them in another format, the document was never provided. The facility's QAPI Plan, last updated 6/19/2024, stated that QAPI concerns, updates, or changes are to be reviewed and discussed at quarterly meetings.
Medical Director Did Not Participate in Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assessment and Assurance (QAA) process quarterly meetings. Review of the Monthly and Quarterly QAA records showed no documented evidence that the Medical Director attended any QAA program meetings from 12/2025 through 05/2026. During interview, the Administrator confirmed the previous Medical Director had not attended any QAA program meetings during that period and stated she should have. In a separate telephone interview, the previous Medical Director also confirmed she had not attended any quarterly QAA meetings from 12/2025 to 05/2026.
QAA Committee Missing Required IPC Member
Penalty
Summary
The facility did not maintain a quality assessment and assurance committee with the required members, including the infection control and prevention officer, as outlined in its policy. Record review showed the facility's Quality Assurance/Assessment and Performance Improvement Plan required the QAA Committee to include the Director of Nursing Services, the Medical Director, the Administrator, at least two other staff members, and the infection control and prevention officer. During the entrance conference, the DON identified IPC T as the facility's infection prevention and control nurse, but the QA committee attendance sign-in sheets dated 10/24/25 and 4/24/26 did not include an IPC. The DON stated she was not certified in infection prevention and control, and the NHA stated the Medical Director, NHA, pharmacist, and DON were the required QAPI members, while also acknowledging that IPC T does not always attend and should attend the meetings.
QAPI Committee Failed to Meet Quarterly and Lacked Required Member
Penalty
Summary
The facility failed to ensure the QAPI committee met at least quarterly and included the required minimum members, specifically the Infection Preventionist. Review of QAPI meeting attendance records dated August 26, 2025, through April 30, 2026, showed that no meeting was held during the first quarter of 2026, with meetings documented on December 30, 2025, and again on April 30, 2026. The April 30, 2026 attendance record also showed that the Infection Preventionist did not attend the meeting. The Nursing Home Administrator confirmed these findings during interview on May 21, 2026, at 11:03 AM.
Failure to Hold Required QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to include all required committee members. Review of QAA Committee meeting sign-in sheets showed only one meeting in August 2025 and one meeting in April 2026. During an interview on 5/21/26 at 1:09 p.m., the Nursing Home Administrator confirmed that the facility did not conduct QAA meetings at least quarterly with all required committee members as required.
QAPI Committee Lacked Documented Infection Preventionist Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance Committee with the required members and to document that the Infection Preventionist attended the Quality Assurance and Performance Improvement meetings on a regular quarterly basis. The report states that the committee was required to include, at a minimum, the DON, the Medical Director or designee, at least three other staff members, one in a leadership role, and the Infection Preventionist, but the facility could not provide documented evidence that the Infection Preventionist was present at the QAPI meetings quarterly. The facility’s QAPI policies described a data-driven program to monitor clinical care, resident safety, regulatory compliance, and operational performance, and identified infection prevention as an area reviewed annually. The facility assessment stated that the infection prevention and control program was headed by a certified Infection Preventionist, and that infection prevention education covered hand hygiene, isolation, standard universal precautions, PPE, and environmental cleaning. Review of quarterly QAPI attendance records from 05/30/2025 to 02/25/2026 showed no documented evidence that the Infection Preventionist attended the meetings, and during interview the Regional Administrator and Administrator stated they knew the regulation and did not know why the Infection Preventionist had not attended the meetings at least quarterly.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.