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F0867
F

Failure to Implement and Maintain QAPI Committee and Infection Control Oversight

Danvers, Massachusetts Survey Completed on 06-18-2025

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 that its Quality Assurance and Performance Improvement (QAPI) Committee met as required and addressed quality deficiencies through the development and implementation of corrective action plans. According to the facility's own QAPI policy, the committee was supposed to meet monthly and include representatives from key departments to monitor, assess, and improve care and operations. However, the Administrator confirmed that the QAPI program was not implemented from June 2024 until February 2025 following a change in ownership, and no QAPI meeting minutes or projects could be found for that period. Additionally, the Medical Director, who began in April 2025, stated that there was no Infection Control Program in place and that infection monitoring, tracking, and data collection were not occurring as expected. The lack of an active QAPI committee and absence of infection control oversight meant that quality gaps, including those related to infection prevention and antibiotic stewardship, were not being systematically identified or addressed during the specified timeframe.

See complete original report
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