QAPI Meetings Lacked Required Members
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 its Quality Assurance and Performance Improvement (QAPI) group included the minimum required members at its quarterly meetings. Review of QAPI attendance records since the last recertification survey showed that the Medical Director was present at only one meeting, despite multiple meetings being held during the review period. During an interview, the Administrator acknowledged that the facility's QAPI policy does not specify which members must be present at the quarterly meetings and was unable to provide documentation to confirm the Medical Director's attendance at more than one meeting. The facility reported a census of 51 residents at the time of the review.