Failure to Ensure Required QAPI Committee Membership and Attendance
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required minimum members, specifically the medical director, at least quarterly as mandated. Review of QAPI meeting attendance records from October 30, 2024, to July 24, 2025, showed that the medical director attended only one meeting during this period. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the medical director (or designee) did not attend QAPI meetings at least quarterly as required by regulation.