Non-compliance in QAPI Committee Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committees included the required attendance of the Medical Director or their designee, and the Infection Control Practitioner at quarterly meetings. Specifically, the Medical Director or their designee did not participate in three out of four QAPI meetings, and the Infection Control Practitioner was absent from two out of four quarterly meetings. This deficiency was identified through a review of the facility's QAPI policy and the attendance sheets for meetings held on specific dates, which showed the absence of signatures from the Medical Director and the Infection Control Practitioner. During an interview, the Administrator acknowledged the issue, stating that the previous Medical Director had attendance problems, and a new Medical Director was hired at the beginning of the year. Additionally, the Administrator noted that the Infection Control Practitioner had not been attending the QAPI meetings, but a new practitioner had been hired and attended the last two quarterly meetings. The facility's policy, last revised in June 2025, requires the participation of key personnel, including the Medical Director and Infection Control Practitioner, in the QAA committee, which was not adhered to, leading to this deficiency.