Failure to Conduct Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were conducted quarterly and that the necessary staff members attended those meetings for three of the six months reviewed. The facility's policy, dated November 30, 2014, required that Quality Assessment and Assurance Committee (QAA) meetings be held at least quarterly, with members including the Executive Director, Medical Director, Director of Nursing, and Infection Preventionist. However, records revealed that the last QAPI meeting was held on December 18, 2024, and there was no evidence of a meeting in March 2025 or a sign-in sheet with all necessary staff members. During an interview on April 3, 2025, the facility's Administrator, who started in March of that year, stated that a QAPI meeting was held on March 20, 2025, with attendees including the Director of Nursing, Activities, Maintenance, Rehab, Social Services, Admission, and Housekeeping, but not the Medical Director. The Administrator was unable to provide a sign-in sheet from all the necessary members for the QAPI meeting held on March 20, 2025.