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F0868
D

Failure to Ensure Required QAPI Committee Attendance

New Castle, Pennsylvania Survey Completed on 06-26-2025

Penalty

No penalty information released
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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 conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all required committee members, as evidenced by a review of facility policy, QAPI meeting attendance records, and staff interviews. Specifically, the Infection Preventionist, who is a required member of the QAPI committee, was not present at the October 2024 and January 2025 meetings. The facility's policy states that the QAPI committee must include the Administrator or designee, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments as requested, and that meetings must occur at least quarterly. The absence of the Infection Preventionist from two quarterly meetings was confirmed by the Corporate Nursing Home Administrator, and there was no evidence of their attendance during the specified periods.

See complete original report
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