Failure to Maintain Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to maintain the required membership and attendance for its Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) committee. Document review showed that the QAPI committee was missing required members, specifically the Director of Nursing (DON) and the Medical Director (MD), at multiple meetings. Sign-in sheets for several meetings confirmed that the DON was absent from all meetings between July 2024 and January 2025, and the MD was absent from meetings between January and April 2025. The facility's own policy requires the QAPI committee to include, at a minimum, the DON, MD or designee, Administrator, Infection Preventionist, and at least two other staff members. The Administrator confirmed that the required members were not present at the identified meetings. No information about residents or their medical conditions is included in the report, and the deficiency is based solely on committee composition and attendance as documented and confirmed by facility leadership.