Infection Preventionist Not Present at Required QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required Infection Preventionist (IP) was present at two out of four Quality Assurance and Performance Improvement (QAPI) committee meetings reviewed. During an interview, the Licensed Nursing Home Administrator (LNHA) confirmed that QAPI meetings were held at least quarterly and that the required members included the administrator, DON, medical director, and other staff. Upon reviewing the QAPI meeting attendance sign-in sheets, the LNHA was unable to identify the IP as present at the meetings held on 4/17/2024 and 10/16/2024. The LNHA also stated he was not aware that the IP was required to attend these meetings. Further review of facility documentation showed that while the IP was off on 1/15/2025, infection control topics were still reviewed with the committee. However, no evidence was provided to show that infection control was reviewed during the 4/17/2024 and 10/16/2024 meetings. The facility's policy requires the IP to be a member of the QAPI committee and for attendance records to be maintained, but these requirements were not met for the specified meetings.