Lack of Governing Body Oversight for QAPI and Infection Control Programs
Penalty
Summary
The facility failed to ensure that its governing body provided oversight and accountability for the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program and the provision of an infection control/antibiotic stewardship program. Review of facility policy indicated that the Administrator is responsible and accountable to the governing body for QAPI implementation, and that QAPI activities should be a standing agenda item for governing body meetings. However, during the survey, the facility was unable to provide documentation related to infection tracking, reporting data, or antibiotic stewardship, and there was no evidence that QAPI had been initiated for these programs. Interviews revealed that the QAPI program had not been implemented from the time of ownership change in June 2024 until February 2025, with no meeting minutes or projects available for that period. The Administrator was unaware that infection control and antibiotic stewardship programs were not being implemented and had not informed the governing body of the lack of QAPI prior to February. Additionally, the President of Operations/owner was not aware of who the governing body representative was for the facility and was not informed about the absence of QAPI activities during the specified period.