Failure to Hold and Document Required QAPI Committee Meetings
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly as required. Review of the Quality Assurance Committee sign-in sheets for the period from January 2024 to March 2025 showed that meetings were held on several dates, but there was no documented evidence of a meeting in June 2024 or for certain other periods. During an interview, the DON stated that the facility's computer system had been hacked and that no paper documentation was available to verify the missing meetings. This lack of documentation and failure to meet the required frequency of QAPI meetings was identified during the recertification/complaint survey.