Failure to Hold QAPI Meetings Quarterly
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 Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis as required. Document review showed that QAPI meetings occurred on 4/16/24, 8/27/24, and 1/7/25, which did not meet the minimum frequency of every three months or quarterly. During an interview, the director of nursing, who leads the QAPI meetings, confirmed that the facility had not been meeting the required schedule and acknowledged that an additional meeting should have been held to maintain compliance. The facility's own QAPI plan, effective 1/2025, specifies that the committee is responsible for meeting at least quarterly.