Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings as required. Review of QAPI meeting attendance sign-in sheets over a period of more than a year showed that the medical director did not attend any of the meetings. This was confirmed during an interview with the administrator, who verified that there was no evidence of the medical director's attendance at any QAPI meeting during the specified timeframe. Additionally, the facility's QAPI policy did not specify the required members, including the medical director, nor did it outline the frequency of attendance for required members.
Plan Of Correction
All residents were immediately assessed and found to have no adverse effects. All QAPI reviewed and ensured that physician was in attendance Quarterly. Education immediately provided by admin to all staff required to be in attendance at QAPI regarding attendance requirements. Admin/Designee to review next 3 QAPI meetings to ensure all necessary attendees are present. Results to be reviewed in QAPI.