Improper Constitution of Quality Assurance Committee
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee was properly constituted, as required by regulations. Specifically, the Director of Nursing was also serving as the Infection Preventionist, which is not permissible. The facility's Quality Assurance and Performance Improvement Plan outlined that the committee should include the Administrator, Medical Director, Director of Nursing, and Infection Preventionist, among others. However, due to staffing issues, the Director of Nursing was fulfilling multiple roles, including that of the Infection Preventionist and Nurse Educator. This dual role was not recognized by the Administrator, who was unaware that the Infection Preventionist should be a separate position. The facility's policy and procedure for Infection Prevention and Control, last revised in 2024, stated that the Infection Prevention and Control Committee should oversee the implementation of infection control policies and practices. During interviews, it was revealed that the facility held monthly meetings, but the responsibility for signing in was left to the staff. The Administrator admitted to being unaware of the requirement for the Infection Preventionist to be a distinct role, which contributed to the deficiency. This oversight had the potential to affect all residents of the facility, as the committee's role is crucial in coordinating and evaluating performance improvement projects.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The QAPI policy was reviewed with no changes. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: Audits of QAPI attendance will be completed to ensure the IP is present. This will be completed x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Administrator by 3/31/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
QAPI meeting records showed the MD was not documented as attending the required quarterly meetings. Review of attendance sheets and minutes for multiple meetings showed the MD was either not signed in or had no evidence of attendance, and the DON agreed the MD had not attended any of the reviewed QAPI meetings. The QAPI policy required the committee to include the MD and meet at least 4 times per year, but it did not address how to ensure MD attendance.
The facility failed to ensure required QAPI committee members attended all QAPI meetings. The Medical Director stated he had not attended a QAPI meeting in a long time and said meetings were scheduled when he could not attend. Review of QAPI sign-in logs showed multiple meetings without the MD’s signature and several meetings without evidence that the ICP attended, with some logs not identifying staff roles and one month lacking a QAPI sign-in record altogether.
The facility failed to maintain a QAA/QAPI committee with the required members for four quarterly meetings. Record review showed the Medical Director was not present at any of the reviewed QAPI meetings, and the ADMN stated the MD either could not or would not attend while making rounds, giving orders, and signing orders during the meetings. The facility’s QAA committee list identified the required members as the Administrator, MD, DON, and ADON.
QAPI Committee Lacked Medical Director Participation: The facility failed to ensure the Medical Director participated in QAPI Committee meetings as required. Review of 13 meeting sign-in sheets showed no documented attendance by the Medical Director, and the Administrator confirmed the MD did not attend or join by phone. The Administrator stated the MD was only in the facility on Wednesdays and meeting times did not always align with that availability.
QAA committee meetings were not held quarterly as required, and the required members were not regularly present. The CNO stated she was covering for the DON while the DON was on leave, but sign-in sheets showed meetings without the DON or covering DON, the IP, or the administrator/board member in attendance. The CNO also stated scheduling conflicts prevented the meetings from occurring on time, despite knowing quarterly QAPI meetings were required.
QAPI meeting attendance sheets showed the IP did not attend two monthly meetings, and the ADM confirmed the IP was absent. The ADM stated the minimum QAPI attendance included the ADM, DON, IP, and three other members, and noted the IP would not be able to address infection control issues or clarify infection control information, concerns, and questions from the team when absent. The facility policy stated the ADM was responsible for ensuring the QAPI program complied with regulatory requirements.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure the medical director (MD-A) attended QAPI meetings at least quarterly. Review of QAPI meeting minutes and attendance sheets for June, August, September, October 2025, and January and April 2026 showed that MD-A was listed on the attendance sheet in June 2025 but did not sign off as attending, and MD-A's name was not on the sign-in sheets for the remaining reviewed meetings. The facility's QAPI quarters were identified as July-September, October-December, January-March, and April-June, and there was no evidence that MD-A attended at least once per quarter as required. During interview, the DON stated she had overseen QAPI since January 2026 and agreed that MD-A was not in attendance at any of the QAPI meetings reviewed. The February 2026 QAPI policy stated the committee was to include the medical director and other appropriate staff and was to meet at least four times per year, but it did not address how to ensure the medical director or designee attended as required.
QAPI Committee Did Not Include Required Members at Meetings
Penalty
Summary
The facility failed to ensure that the required QAPI committee members attended all QAPI meetings. During an interview, the Medical Director stated he had not attended a QAPI meeting in so long that he could not recall the last one, and he said the facility scheduled meetings at times he could not attend despite him telling them his availability. The Administrator stated she had only been employed at the facility for one week and said she would have to put a correction plan in place for QAPI. Review of the prior year’s QAPI sign-in logs showed multiple meetings without the Medical Director’s signature and several meetings without evidence that the infection preventionist attended. The records also showed meetings where staff signatures were present but roles were not identified, making it impossible to determine whether the infection preventionist attended. In addition, no sign-in log was received for January 2026 to show that the required monthly QAPI meeting was held, and some meetings were documented as ad hoc rather than monthly QAPI meetings.
QAPI Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to maintain a quality assessment and assurance committee with the required members for four quarterly QAPI meetings reviewed. Record review of the Quality Assurance Performance Improvement attendance sign-in forms showed that the Medical Director was not present for the 3rd Quarter 2025 meeting, the 4th Quarter 2025 meeting, the January 2026 meeting, or the 03/10/2026 meeting. The facility’s QAA committee document listed the required members as Administrator, MD, DON, and ADON. During an interview on 06/17/2026 at 12:10 PM, the ADMN stated that no Medical Director was present for QAPI during the last four quarters. He stated the MD either could not or would not attend, and that the MD was making rounds, giving orders, and signing orders during QAPI meetings. The facility policy titled Quality Assurance and Performance Improvement stated that the facility shall develop, implement, and maintain an ongoing facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.
QAPI Committee Lacked Medical Director Participation
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement (QAPI) Committee meetings as required for 13 of 13 reviewed meetings held from 05/30/2025 through 05/29/2026. A facility policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated 04/2014, stated the QAPI Committee shall include the Medical Director as a member. Review of the QAPI meeting sign-in sheets for each of the 13 meetings showed no documented evidence that the Medical Director attended. During interviews on 06/12/2026, the Administrator reviewed the sign-in sheets and confirmed the Medical Director had not attended the meetings, stated the Medical Director was in the facility on Wednesdays but the meetings did not always occur on Wednesdays, and stated the Medical Director's availability was limited. The Administrator also stated the Medical Director did not participate by phone and suggested the facility may need to hold QAPI meetings at times when the Medical Director was in the facility.
QAA Committee Did Not Meet Quarterly With Required Members Present
Penalty
Summary
The facility failed to have the Quality Assessment and Assurance (QAA) group meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, and the required committee members were not in regular attendance at the QAA meetings. During interview, the Chief Nursing Officer (CNO) stated she was covering for the DON while the DON was on leave since May 2026, and she also stated the last QAA meeting had been held in May, but she was unable to attend because of scheduling conflicts. The facility’s QAA attendance sign-in sheets were reviewed and showed that the meetings dated 7/10/2025, 12/18/2026, and 5/07/2026 did not document attendance by the DON or covering DON, the Infection Preventionist (IP), or the facility administrator or board member. During the interview, the CNO stated she was the one who attended the facility’s QAA meetings acting as the board member/administrator, but she had been unable to attend the meetings held on 7/10/2025, 12/18/2025, and 5/07/2025 due to scheduling conflicts. She acknowledged that QAPI committee meetings had to occur quarterly, but stated the facility was unable to schedule them on time because of scheduling conflicts. The facility’s policy titled Performance Improvement Plans, revised 2/2026, stated that the governing body was ultimately responsible and accountable for oversight and priority setting for the safety and quality of care, treatment, and services provided.
QAPI Meeting Lacked Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure the Infection Preventionist attended the February 2026 and May 2026 QAPI meetings. Record review of the monthly QAPI meeting attendance sheets dated 2/20/2026 and 5/22/2026 showed no signature for the Infection Preventionist. During a concurrent interview and record review on 6/5/2026 at 11:06 a.m. with the Administrator and the Director of Nursing, the attendance sheets were reviewed and the Administrator stated the Infection Preventionist did not attend those meetings. The Administrator stated the minimum staff in attendance for QAPI meetings were the Administrator, DON, Infection Preventionist, and three other members, and stated that if the Infection Preventionist was not in the meetings, the Infection Preventionist would not be able to address infection control issues or clarify infection control information, concerns, and questions from the team. Review of the facility policy titled Quality Assurance and Performance Improvement, dated 2/2020, indicated the Administrator was responsible for assuring the facility's QAPI program complied with federal, state, and local regulatory agency requirements.
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