Failure of Governing Body to Oversee QAPI Program
Penalty
Summary
The facility failed to ensure that its governing body was responsible and accountable for the Quality Assurance Performance Improvement (QAPI) program. Documentation review showed that the QAPI Plan assigned ultimate oversight of the QAPI committee to the governing body, with the owner/president having direct oversight and the QAPI committee, including the medical director, responsible for compliance and quality improvement. However, attendance records for QAPI meetings from January through June 2025 revealed that neither the Medical Director (MD) nor the Nursing Home Administrator (NHA) attended any of the monthly meetings during this period. A memorandum indicated that the designated NHA had appointed another employee (Employee 3) as the full-time, on-site administrator, while the NHA remained engaged with facility operations and communicated regularly with Employee 3. Despite this arrangement, Employee 3 confirmed that the NHA and MD did not attend QAPI meetings and that he did not consistently share QAPI meeting minutes or updates with the NHA. No written documentation was provided to show communication between Employee 3 and the NHA or governing body regarding QAPI matters or ensuring MD attendance at QAPI meetings.