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F0868
D

Required QAPI Committee Members Absent from Meetings

Marienville, Pennsylvania Survey Completed on 05-08-2025

Penalty

No penalty information released
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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 the required attendance of the Director of Nursing (DON) and the Infection Preventionist at two of four quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings. Review of the facility's policy indicated that the QAPI steering committee must include the Administrator, DON, Infection Control, and Medical Director, in accordance with CMS regulations. Examination of the QAPI Committee attendance records showed that the DON was not present at the October 2024 meeting, and the Infection Preventionist was not present at the February 2025 meeting, as evidenced by the absence of their signatures on the attendance sheets. During an interview, the Nursing Home Administrator confirmed that there was no evidence of attendance for these required members at the specified meetings and acknowledged that their presence was required.

See complete original report
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