QAPI Committee Failed to Meet Quarterly and Lacked Required Members
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly as required by policy, with no meetings held during the first and second quarters of 2025. A review of the QAPI meeting minutes from the previous quarter showed that the Medical Director and Pharmacist were not in attendance, and the Nurse Practitioner was not involved or invited to participate in the QAPI program. Staff interviews confirmed that the Medical Director was not engaged in the QAPI process and that the Nurse Practitioner, who was present on site daily, was not asked to attend in the Medical Director's absence. The Administrator reported that the previous Medical Director worked remotely and was unable to attend meetings on site, and no attempts were made to have the Medical Director participate virtually. Instead, the Administrator canceled the QAPI meetings, resulting in the committee not convening since November. The facility's QAPI policy required specific committee membership and quarterly meetings, but these requirements were not met for three consecutive quarters, potentially impacting all residents. The Administrator acknowledged that the facility had not met expectations in areas such as weights, falls, and grievances, and that the lack of QAPI follow-through contributed to unsuccessful corrective efforts.