QAPI Committee Lacks Documentation and Required Review Processes
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to meet several regulatory requirements over four reviewed quarters. Meeting minutes from multiple dates showed that the committee did not document attendance, making it impossible to confirm if required members, such as the DON, medical director, infection preventionist (IP), and administrator, were present. The minutes only included a typed list of members without specifying who attended or was absent. Additionally, there was no evidence that the committee received or reviewed regular reports from the IP regarding infection control activities, process and outcome surveillance, outbreaks, staff illness, or the Antibiotic Stewardship Program (ASP). The QAPI director confirmed that while the IP sometimes gave verbal updates, these were not documented, and there was no record of discussion, goals, or plans for improvement. Furthermore, the committee did not document the review of State Agency (SA) or incident reports, as required by facility policy. Interviews with the QAPI director, administrator, and DON revealed uncertainty about whether these reports were discussed with the medical director and confirmed the absence of documentation regarding their review. The facility's QAPI policy mandates maintaining documentation to confirm compliance with CMS requirements, including the composition of the committee and the review of relevant reports, but these requirements were not met during the period reviewed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
QAA Committee Attendance and Documentation Deficiencies: The facility failed to maintain and account for scheduled QAA meetings. Record review and interviews showed missing attendance forms for several months, the ADON identified as the QAA lead was absent from multiple meetings, and the QAA/QAPI binder contained some data without a documented plan or leadership, with no data for the final months reviewed.
QAPI committee meetings did not consistently include the required members or designees, and infection control information was not reliably presented. Meeting minutes showed the Administrator and Medical Director were absent from some meetings without designees, and the DON/IP did not provide documented infection control tracking even though a COVID outbreak had occurred. Interviews confirmed that when the minutes stated no new concerns, infection control tracking and the outbreak were not discussed.
QAPI Committee Lacked Required MD Participation: The facility failed to maintain a QAPI committee with the required members because the MD, or a representative, did not attend multiple QAPI meetings reviewed. Record review showed no evidence of MD attendance at the meetings, and the ADM stated she expected the MD to attend and did not know why he had not been present. The facility policy required an ongoing, facility-wide, data-driven QAPI program focused on resident outcomes and quality of life.
The facility failed to ensure the Medical Director or designee attended a QAA Committee meeting. The attendance sheet showed the Medical Director was absent, and the ADMIN stated no additional documentation explained the absence. The facility's QAPI policy required the committee to include the Medical Director or designee.
The facility's Medical Director failed to attend two of five reviewed quarterly QAPI meetings. Surveyors found no MD signature on the QAPI sign-in sheets for two quarterly meetings, and the LNHA acknowledged there was no evidence the MD attended either meeting. The facility's QAPI policy listed department heads as committee members but did not list the MD as a QAPI member.
Failure to Hold Required QAA Meetings: The facility failed to conduct QAA meetings at least quarterly with all required committee members for three of four quarterly meetings. The NHA was unable to locate QAPI sign-in sheets for the review period, and later confirmed the facility did not meet the required QAA meeting schedule.
QAA Committee Attendance and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain and account for scheduled Quality Assessment and Assurance (QAA) meetings. Based on record review and interviews, the surveyor found that the facility did not have documented attendance for several months of QAA meetings, including no attendance forms in the QAA/QAPI binder for August 2025 through December 2025. The surveyor also reviewed attendance for the last 6 months and found that the Assistant Director of Nursing (ADON), who was identified by the Nursing Home Administrator (NHA) and Director of Nursing (DON) as the facility’s QAA lead and the person responsible for running and coordinating the committee, was not in attendance from January 2026 through April 2026. During the review of the QAA/QAPI binder, some months contained data, but no direct plan or leadership was identified based on the data. The months of May and June had no data in the binder. The NHA stated that the ADON was responsible for the QAA committee, and the DON confirmed that the ADON was the designated lead for the QAA committee and meetings. The surveyor further reviewed the concern with the NHA that the lead for the QAA committee was only documented to be in attendance 2 out of the 11 months reviewed.
QAPI Committee Lacked Required Attendance and Infection Control Reporting
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee had the required members or designees attend quarterly meetings and failed to ensure the Infection Preventionist provided relevant infection control information to the committee. Facility records showed QAPI meetings were held, but the Medical Director and Administrator were absent from some meetings without documented designees attending in their place. The facility QAPI plan stated the committee should meet at least quarterly and include the Director of Nursing Services, the Medical Director or designee, the Nursing Home Administrator, and the Infection Preventionist, and that if any member could not attend, a supervisor or delegate would present their data. Meeting minutes documented that the DON/Infection Preventionist attended, but infection control information was not consistently reported. One set of minutes stated no new infection control concerns were identified for the quarter, and there was no infection control tracking information documented. Another set of minutes also lacked documentation that infection control tracking was discussed. During interviews, the DON/IP stated there had been a COVID outbreak in January and confirmed that if the minutes said no new concerns were reported, then infection control tracking or the COVID outbreak was not discussed. The Administrator stated she did not know whether the Medical Director had a designee for QAPI meetings and assumed there was no infection prevention tracking report when the minutes documented no new information.
QAPI Committee Lacked Required MD Participation
Penalty
Summary
The facility failed to maintain a quality assessment and assurance committee with the required members for 10 of 11 QAPI meetings reviewed. Record review of the sign-in sheets for the September 2025 through June 2026 QAPI meetings showed no evidence that the MD attended any of those meetings. The report states that the facility did not ensure the MD, or a representative, attended the QAPI meetings during that period. During an interview on 07.16.2026 at 1:00 pm, the ADM stated her expectation was that the MD would attend QAPI meetings and that it would be beneficial if he attended every meeting. The ADM stated she did not know why the MD had not attended the QAPI meetings and stated she did not feel that his absence had any effect on resident care. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program states the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program focused on indicators of outcomes of care and quality of life for residents.
QAA Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to ensure the Medical Director or designee attended the Quality Assessment and Assurance Committee meeting held on 6/26/2026 as required. Review of the QAA Steering Committee attendance sign-in sheet showed the Medical Director did not attend the meeting. During an interview on 7/16/2026 at 3:50 p.m., the Administrator stated the Medical Director or designee did not attend the QAA Committee meeting and that no additional documentation was available regarding the Medical Director's absence. The Administrator also stated the Medical Director's participation is essential to provide clinical oversight, educate nursing staff, and support quality improvement activities. Review of the facility's QAPI policy, revised 3/28/2024, showed committee members must include the Medical Director or designee.
Medical Director Did Not Attend Required QAPI Meetings
Penalty
Summary
The facility Medical Director failed to attend mandatory quarterly QAPI meetings for two of five quarterly meetings reviewed. During the entrance conference, the survey team requested quarterly QAPI sign-in sheets, a list of QAPI committee members, and the facility's QAPI policies and procedures. Review of the committee member list showed the Medical Director was listed as a member, but the facility-provided sign-in sheets for the 2025 4th quarter QAPI meeting and the 2026 2nd quarter QAPI meeting did not include the Medical Director's signature. The LNHA later acknowledged there was no evidence that the Medical Director attended either meeting and stated the Medical Director was a key member of the QAPI committee. The facility's undated QAPI policy, however, listed each department head as committee members and did not list the Medical Director as a QAPI committee member.
Failure to Hold Required QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three of four quarterly meetings, covering the period from August 2025 through March 2026. Review of the facility policy, Center Quality Assurance Performance Improvement Process, showed that QAPI activities were to be integrated across all care and service areas and include clinical care, quality of life, and resident choice. During an interview on 7/14/26 at 10:35 a.m., the NHA was unable to locate the sign-in sheets for the QAPI meetings from August 2025 through March 2026. During a later interview on 7/16/26 at 10:00 a.m., the NHA confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members as required.
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