Failure to Maintain QAPI Meeting Documentation
Penalty
Summary
Facility staff failed to maintain evidence of a continuous Quality Assurance and Performance Improvement (QAPI) program, as required by their policy, for nine out of ten quarters reviewed. During the survey, the administrator was unable to provide complete QAPI meeting attendance records for the period between Q4 of 2022 and Q4 of 2024. The records that were provided were incomplete, with missing sign-in sheets, undated documents, and an inability to identify the specific dates when meetings took place. Additionally, some records showed that required attendees, such as the infection preventionist and the director of nursing, were absent from certain meetings. Interviews with administrative staff confirmed that while QAPI meetings were reportedly held monthly or at least quarterly, there was insufficient documentation to support this claim. The facility's QAPI policy required regular, at least quarterly, meetings, but the lack of proper records and sign-in sheets meant there was no verifiable evidence that the QAPI program was being consistently implemented or monitored during the review period.