QAPI Committee Lacks Documentation and Required Review Processes
Penalty
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.