Failure to Conduct Quarterly QA Meetings
Summary
The facility failed to conduct quarterly Quality Assurance (QA) meetings, which is a requirement for maintaining quality standards. This deficiency was identified through a review of QA meeting minutes and an interview with the Administrator. The review revealed that there were no QA meeting minutes available prior to October 2024, indicating that the facility did not hold these meetings before the Administrator developed the QA program upon his arrival. This lapse had the potential to affect all 110 residents in the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to conduct and document required QAPI activities, with no QAPI records for most of the review period and no active Performance Improvement Projects. The Assistant Administrator reported that current leadership could not locate prior QAPI documentation and that expected monthly QA and quarterly QAPI meetings were not evidenced. Review of maintenance, pest control, Resident Council, and grievance records showed that administration was aware of ongoing resident and family concerns that persisted without resolution. The survey also identified an ineffective staff training program on QAPI, communication, and behavioral health, and there was no documentation that the governing body was informed of or acting on the identified issues.
Surveyors found that the facility did not hold QAA/QAPI meetings on a quarterly basis and did not include the medical director as a participant. Review of meeting sign-in sheets and minutes showed that the medical director did not attend documented meetings, and the Administrator acknowledged that no QAPI meeting was held for one quarter and that the medical director had never attended these meetings. The Administrator also reported there was no written policy governing quarterly quality assurance meetings, despite an expectation that they occur quarterly with medical director involvement, affecting all residents in the facility.
The facility did not ensure its QAA committee met at least quarterly or maintained required membership. The written QAPI program and policy called for regular, at least monthly, QAA/QAPI meetings, but review of meeting minutes and sign-in sheets showed only four meetings over an extended period, with gaps of about four and five months between sessions. Attendance records also showed that no medical provider participated in one of the meetings. In an interview, the Administrator confirmed there were no additional QAA/QAPI meetings during the identified gap period, resulting in noncompliance with regulatory requirements for QAA committee frequency and composition.
QAPI committee meetings were not documented as held for two reviewed quarters, and the Medical Director or designated physician representative was not documented as attending the required quarterly QAPI meetings. The facility’s QAPI policy described the program as comprehensive and ongoing, but it did not specify physician participation or attendance expectations, and the DON and NHA acknowledged the missing documentation.
QAA Meeting Attendance Deficiency: The facility failed to ensure all required QAA members attended quarterly meetings. Review of QAPI attendance records showed the required team had not all attended a quarterly meeting since 5/27/25. The DON acknowledged that staff turnover, leadership changes, and the Infection Preventionist being pulled to work as a charge nurse affected attendance. The QAPI plan listed the required participants, including the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director, Activity Director, Social Worker, and Dietary Manager.
QA committee failed to receive infection preventionist reports on employee surveillance for 4 of 4 quarters reviewed. QAPI minutes showed resident infection counts were discussed, but there was no documentation of employee surveillance review, benchmarks, goals, or data analysis. The administrator acknowledged there was no evidence the IP brought employee surveillance to QAPI for oversight, despite the QAPI plan and infection control policy calling for committee review of infection-related data.
Failure to Conduct and Document Required QAPI Activities and Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program met regulatory requirements, including conducting QAPI meetings at least quarterly and maintaining documentation of QAPI activities. Surveyors reviewing four quarters of records found no QAPI documentation for three of the four quarters in 2025, with only one quarter in 2026 having documentation. The Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but there was no current Performance Improvement Project in place. During the survey, which was extended after substandard quality of care was identified, surveyors reviewed maintenance logs, pest control logs, Resident Council minutes, and grievance logs. These records showed that administration was aware of ongoing issues and concerns voiced by residents and families that continued for several months without resolution. The survey also determined that the facility did not have an effective training program, including required training on QAPI, effective communication, and behavioral health. Despite the identification of substandard quality of care and other issues by the survey team, there was no documentation that the governing body was aware of or acting on these findings.
Failure to Hold Quarterly QAA/QAPI Meetings With Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA)/QAPI program met regulatory requirements for quarterly meetings and required membership. Review of Quality Assurance meeting sign-in sheets and minutes dated 1/23/25, 3/13/25, 7/30/25, and 1/9/26 showed no signature from the facility’s medical director, indicating the medical director did not attend these meetings. In an interview on 3/24/26 at 11:20 AM, the Administrator (V1) stated that a QAPI meeting was not held for the 4th quarter of 2025 and that meetings were only held in January, March, and July of 2025. V1 further stated that the medical director had never attended the QAPI meetings. On 4/13/26 at 3:00 PM, V1 confirmed there was no facility policy related to quarterly quality assurance meetings, but acknowledged that meetings were supposed to be held quarterly and that the medical director should be in attendance. The facility’s daily census report dated 3/17/26 documented that 67 residents were residing in the facility at the time of the survey. No additional resident-specific medical histories or conditions were described in the report beyond the total number of residents potentially affected.
Failure to Hold Quarterly QAA Meetings With Required Membership
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. The facility’s Quality Assurance and Performance Improvement (QAPI) Program, reviewed on 04/28/2025, outlined a purpose focused on continuous evaluation of facility systems, ensuring care delivery systems function consistently and accurately, preventing deviations from care processes, identifying issues and opportunities for improvement, and developing and implementing plans to correct identified areas. The facility’s QAPI Committee policy, last reviewed in December 2022, specified that the committee would meet monthly at an appointed time, with special meetings called as needed. Review of QAPI meeting minutes and sign-in sheets showed meetings held on 05/29/2025, 09/26/2025, 10/31/2025, and 03/24/2026, revealing an approximate five-month lapse between the 10/31/2025 and 03/24/2026 meetings, and an approximate four-month interval between the 05/29/2025 and 09/26/2025 meetings. Further review of attendance records showed that no medical provider attended the 03/24/2026 meeting. During an interview on 04/22/2026, the Administrator, who had been in the role since February 2026, confirmed that a QAPI meeting was held at the end of March 2026 and did not identify any additional meetings between October 2025 and March 2026. These findings demonstrate that the QAA committee did not meet at least quarterly and lacked required membership at one meeting, in violation of Title 10 NYCRR 415.27(c)(1).
QAPI Committee Meetings and Physician Participation Not Documented
Penalty
Summary
The facility failed to ensure that required quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were conducted and failed to ensure the Medical Director or a physician designated by the Medical Director attended the required quarterly QAPI meetings for two of four quarters reviewed, specifically Quarters 3 and 4 of 2025. Facility documentation showed the QAPI policy, last reviewed May 1, 2025, described a comprehensive, ongoing program to review data and care practices, but it did not specify required participation by the Medical Director or a designated physician and did not outline expectations for attendance or accountability at quarterly QAPI meetings. A review of available QAPI committee meeting sign-in sheets and supporting documentation showed the facility could not provide evidence that required quarterly QAPI committee meetings were held during August 2025 through December 2025. The facility also could not provide documentation that the Medical Director or a designated physician representative attended QAPI meetings during July 2025 through December 2025. During an interview on April 17, 2026, the DON and NHA acknowledged the facility was unable to provide documentation supporting the required quarterly meetings and acknowledged that the Medical Director or designated physician representative had not attended the identified QAPI meetings.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Review of QAPI meeting attendance sign-in sheets from March 2025 through April 2026 showed that all required team members had not attended a quarterly QAA meeting since 5/27/25. During an interview on 4/15/26 at 12:40 PM, the DON acknowledged that not all required team members had attended the QAA meeting quarterly and stated that staff turnover and leadership changes had affected attendance. She also said the Infection Preventionist had sometimes been required to work on the floor as a charge nurse and therefore had not always been able to attend the meetings. The facility’s QAPI Plan, updated 3/1/26, stated the facility would meet monthly to discuss ongoing or new issues in the nursing home, and identified the required participants as the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director at minimum every 3 months, Activity Director, Social Worker, and Dietary Manager.
QA Committee Failed to Review Employee Surveillance Data
Penalty
Summary
The Quality Assurance (QA) committee failed to receive reports from the infection preventionist regarding employee surveillance for 4 of 4 quarters reviewed. Review of the QAPI meeting minutes for Quarter 1, Quarter 2, Quarter 3, and Quarter 4 showed discussion of resident infection data, including totals for UTIs, skin infections, and respiratory infections, but there was no indication that employee surveillance was reviewed or discussed in any quarter. The minutes also did not show benchmarks, goals, or analysis of the infection data, and Quarter 4 minutes documented only that resident infections were discussed in numbers without data review or analysis. During interview on 4/15/26 at 3:45 p.m., the administrator stated she was in charge of PIP and the DON was in charge of the rest of the QAPI discussion and documentation. The administrator agreed there was no evidence that the infection preventionist had brought employee surveillance to QAPI for oversight. Review of the February 2026 QAPI plan stated the committee would make quality improvement decisions based on data analysis and include representatives from all departments, and review of the January 2026 Infection Control Coordinator policy stated the infection control coordinator was to report compliance information to the Administrator and QA committee and maintain infection logs for staff and residents.
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