QAPI Committee Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with all required committee members. Review of QAPI sign-in sheets showed that a meeting was held on 5/15/25, but the Nursing Home Administrator (NHA) and the Infection Preventionist did not attend. Additionally, there were no QAPI meetings held in April or June of 2025. During an interview, the Director of Nursing (DON) confirmed that the NHA did not attend the meeting and that the facility did not have an Infection Preventionist. The facility's policy requires the QAPI committee to include the DON, Medical Director or designee, three other staff members (including the administrator), and the infection control and prevention officer, and to meet at least quarterly. These requirements were not met, affecting all 38 residents in the facility.