Failure to Ensure Required QAPI Committee Participation by Key Staff
Penalty
Summary
Facility staff failed to ensure that both the social service director and the medical director participated in the required monthly Quality Assessment Performance Improvement (QAPI) committee meetings. Review of QAPI sign-in sheets revealed that the medical director was on a leave of absence for certain months, and the social service director was also marked as on leave for other months. During these absences, there was no designated person for the medical director, and the only social services worker, who also served as the director, was absent. Staff stated that information from the QAPI meetings was shared with absent members during risk management meetings, but the sign-in roster did not reflect participation by a covering medical director. Additionally, the staff member who acted as the designee for the social services director did not have training in social services, and there was no qualified designee for the medical director during the periods of absence.