Certified Infection Preventionist Absent from QAA Meetings
Penalty
Summary
The facility failed to ensure that a certified Infection Preventionist (IP) attended and participated in the Quality Assessment and Assurance (QAA) meetings as required. According to the facility's QAPI policy, the QAA committee must include the Executive Director, Director of Nursing (DON), Medical Director, Infection Preventionist, and three other staff members, with all members present at monthly meetings. Review of QAA meeting agendas and minutes for the quarter from October to December 2024 showed that the IP did not attend any of the meetings. Instead, the DON signed as both the DON and the IP, but the facility could not provide evidence that the DON was officially certified as an IP or working in that role beyond her regular duties as DON. During an interview, the Executive Director confirmed that the facility lacked documentation to verify the DON's certification as an IP and acknowledged that not all required members attended the QAPI meetings. This deficiency had the potential to affect all 108 residents residing in the facility, as the absence of a certified IP in QAA meetings could impact infection prevention oversight. No additional information was provided prior to the end of the survey.