Lack of Documentation for Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to maintain proper documentation of the Medical Director's or designee's attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, which are required to occur at least quarterly. Record review revealed that, except for one documented instance in April 2025, there was no evidence of a medical provider or director attending QAPI meetings from September 2024 to March 2025, and from May 2025 to July 2025. Staff interviews confirmed that while QAPI meetings were held monthly (excluding July and December), there were no sign-in sheets to verify attendance, and the facility relied on meeting minutes to record attendees. Staff also indicated that the Medical Director or designee sometimes attended via video conferencing, but this was not consistently documented. The facility's QAPI policy requires the Medical Director to be a member of the committee and for meetings to occur at least quarterly. Despite requests for sign-in documentation to confirm the Medical Director or designee's attendance at required meetings, no such records were provided during the survey. This lack of documentation means the facility could not demonstrate compliance with regulatory requirements for QAPI committee composition and meeting frequency.