Infection Preventionist Absence and Lack of Antibiotic Stewardship Review
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) at one of the seven Quality Assurance and Performance Improvement (QAPI) meetings, specifically the 3rd Quarter meeting dated 10/17/24. The absence of the IP was confirmed by the Licensed Nursing Home Administrator (LNHA) during a review of the QAPI sign-in sheets. Additionally, the facility did not review the Antibiotic Stewardship (AS) data during the QAPI meetings as required. The LNHA was unable to locate the AS data in the QAPI binder, although other departmental information was present. The facility's policy on Antibiotic Stewardship mandates that the IP is responsible for infection surveillance and data collection, which should be reported to the QA committee. However, during the review, the LNHA acknowledged that the AS information was not available in the QAPI binder, despite being printed and reviewed at meetings. The surveyor noted that the AS tracking data from July 2024 to the present was printed by the President of Nursing on 2/17/25, but it was not included in the QAPI review. This oversight indicates a failure to adhere to the facility's policies on infection control and quality assurance processes.
Penalty
Resources
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The facility did not provide documentation that the Medical Director attended or participated in required quarterly QA committee meetings, as sign-in sheets lacked the Medical Director's signature and no alternative evidence was available. This failure to document participation affected all residents, as the QA committee did not meet the required membership per facility policy.
The facility did not document required quarterly QAA meetings with all mandated members present, as sign-in sheets were missing or incomplete for several quarters. Key committee members, such as the Medical Director, DON, and Infection Preventionist, were absent from some meetings, and the Administrator confirmed these lapses. This deficiency had the potential to affect all residents in the facility.
The QAPI committee failed to meet at least quarterly, as only one sign-in sheet was available for review and the Administrator confirmed no additional documentation of meetings. This had the potential to affect all 44 residents in the facility.
The facility did not ensure the medical director attended QAPI meetings, as shown by a review of attendance records over an extended period and confirmed by the administrator. The facility's QAPI policy also lacked details on required members and attendance frequency.
The facility did not ensure its QAPI committee included all required members, with the Medical Director's attendance undocumented and the Infection Preventionist absent or uncertified for several meetings. Meeting minutes and sign-in sheets lacked evidence of proper participation, and facility policies did not specify committee requirements.
The facility did not ensure that all required QAPI committee members, including the Medical Director, a governing body representative, and the Infection Preventionist (IP), attended quarterly meetings as required. Documentation showed repeated absences and missing records, and the facility could not provide evidence of IP certification for staff who temporarily filled the role. This deficiency affected all residents.
Lack of Documented Medical Director Participation in QA Committee Meetings
Penalty
Summary
The facility failed to provide evidence that the Medical Director attended and participated in the required quarterly Quality Assurance (QA) committee meetings. Review of the QA meeting sign-in sheets for four consecutive quarters showed that the Medical Director did not sign the attendance paperwork. During staff interview, the Administrator confirmed that the Medical Director was required to attend and participate in each quarterly QA meeting, and acknowledged that there was no documentation, aside from a statement that the Medical Director attended by telephone, to verify participation. The facility's policy specifies that the QA committee must include the Medical Director, Administrator, Infection Preventionist, Director of Nursing, and at least two other care partners. This deficiency had the potential to affect all 58 residents in the facility, as the required committee composition and participation were not documented as required.
Failure to Hold Required QAA Meetings with All Mandated Members
Penalty
Summary
The facility failed to hold required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated members present, as evidenced by a review of QAA meeting sign-in documentation, staff interviews, and facility policy. There was no documentation of QAA meetings for the first, second, and third quarters of 2024. For the fourth quarter of 2024, while a meeting was documented, there was no sign-in sheet to confirm the attendance of all required members. Additionally, meetings held in early 2025 were missing attendance from key members, including the Medical Director, Director of Nursing, and Infection Preventionist. The Administrator confirmed during an interview that there was no documentation of quarterly QAA meetings prior to the fourth quarter of 2024 and that not all required members were present for subsequent meetings. The facility's policy specifies that the QAA committee must include the administrator (or designee), director of nursing services, medical director, infection preventionist, and representatives from various departments as needed, and that meetings must occur at least quarterly. The lack of proper documentation and attendance had the potential to affect all residents, with a facility census of 57 at the time of the survey.
QAPI Committee Failed to Meet Quarterly
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee did not meet at least quarterly as required. Facility documentation review showed only one QAPI committee sign-in sheet for May 2025, with no evidence of additional meetings. During an interview, the Administrator confirmed that the May 2025 sign-in sheet was the only documentation available to support QAPI meetings. No further information was provided to indicate that other meetings had occurred. This deficiency had the potential to affect all 44 residents residing in the facility.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings as required. Review of QAPI meeting attendance sign-in sheets over a period of more than a year showed that the medical director did not attend any of the meetings. This was confirmed during an interview with the administrator, who verified that there was no evidence of the medical director's attendance at any QAPI meeting during the specified timeframe. Additionally, the facility's QAPI policy did not specify the required members, including the medical director, nor did it outline the frequency of attendance for required members.
Plan Of Correction
All residents were immediately assessed and found to have no adverse effects. All QAPI reviewed and ensured that physician was in attendance Quarterly. Education immediately provided by admin to all staff required to be in attendance at QAPI regarding attendance requirements. Admin/Designee to review next 3 QAPI meetings to ensure all necessary attendees are present. Results to be reviewed in QAPI.
QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee included the minimum required members and met the participation requirements. Review of QAPI meeting sign-in sheets from July 2024 through February 2025 showed no evidence of attendance by the Medical Director, and the Infection Preventionist (IP) was not present at all required meetings, with gaps in attendance and certification. The sign-in sheets did not document the Medical Director's virtual attendance, and there was no written evidence of his participation in the meeting minutes. Additionally, the previous IP left in August 2024, and the new IP did not obtain the required certification until January 2025, leaving a period without a qualified IP present at meetings. Interviews with the DON confirmed that the Medical Director typically attended QAPI meetings by phone due to personal circumstances, but this was not documented. The Medical Director himself could not recall his last attendance and stated his participation was usually virtual, with updates provided by the facility. The facility's QAPI policy, last revised in October 2017, did not specify committee member requirements, and no other relevant policies were provided. These findings indicate the facility did not maintain the required composition and documentation for its QAPI committee, potentially affecting all residents.
Failure to Ensure Required QAPI Committee Members Attend Quarterly Meetings
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement (QAPI) committee attended meetings at least quarterly, as mandated. Review of QAPI meeting minutes and sign-in sheets from January 2024 through February 2025 showed that the Medical Director did not attend several meetings between March and July 2024, and a member of the facility's governing body was not present until January 2025. Additionally, there was no evidence that the Infection Preventionist (IP) was present at QAPI meetings as required, and the facility could not provide IP certification for staff who temporarily covered the IP role. There were also missing meeting records for November and December 2024. Facility policy required specific staff, including the Medical Director/Physician, Administrator, and others, to participate in QAPI meetings, but did not initially specify the IP as a required member. However, a later policy update clarified that the IP must attend each QAPI meeting and report on infection prevention and control. Despite this, sign-in sheets and interviews confirmed the IP's routine absence from QAPI meetings, and the facility was unable to provide documentation to show compliance with these requirements. This deficiency affected all 54 residents in the facility.
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