Required QAPI Committee Members Absent from Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance Performance Improvement (QAPI) Committee, specifically the Medical Director and the Nursing Home Administrator (NHA), attended at least one meeting in two out of three quarters reviewed. Attendance sign-in sheets for the QAPI meetings from January through June 2025 did not show participation by either the Medical Director or the NHA. Instead, the Executive Director (Employee 3) signed in as the NHA, but later confirmed during a staff interview that he is not the NHA and that neither the NHA nor the Medical Director had attended the QAPI meetings. Employee 3 also stated that while he communicates with the NHA regularly by phone, he does not necessarily send QAPI meeting minutes for review.