Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the consistent participation of the Medical Director in the Quality Assurance & Performance Improvement (QAPI) meetings, as required by their policy. The policy, last revised in December 2024, mandates the involvement of the Medical Director in these meetings to study, plan, analyze, and validate specific areas for improvement in resident care outcomes. However, a review of the attendance sheets for the QAPI meetings revealed that the Medical Director did not attend the meetings held in August 2024 and January 2025. During interviews, the Director of Nursing confirmed that the Medical Director's absence was evident due to the lack of their signature on the attendance sheets. The Administrator stated that the Medical Director was invited to all meetings but missed one due to a scheduled cataract surgery. The last recorded attendance of the Medical Director was in an unspecified month in 2024.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1: The Medical Director was given the updated QAPI policy to reflect that if the medical director is unable to make a QAPI meeting, he must send a designee. Element #2: The medical director reviewed the last 2 QAPI minutes and reports. Element #3: The QAPI policy will be updated to reflect that if the medical director is unable to make a QAPI meeting, he will send a designee. Element #4: An audit tool will be developed by the administrator to ensure compliance of QAPI meetings. The administrator will audit the next 3 QAPI meetings to ensure the medical director attends. The administrator will present the findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5: Administrator 5/01/2025