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.