Failure to Ensure Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, specifically not ensuring the Medical Director or a representative attended at least quarterly QAPI meetings. Record review of attendance sign-in forms for QAPI meetings over the past year showed that the Medical Director attended only one meeting, despite the requirement for quarterly attendance. Interviews with the Administrator and Regional RN Consultant confirmed that the Medical Director's participation was infrequent, and the RN Consultant was unaware of the lack of attendance. The facility's policy required the Medical Director to attend quarterly, but this was not followed. The deficiency was identified through interviews and review of meeting attendance records, which documented the absence of the Medical Director from the majority of QAPI meetings. The Administrator acknowledged that while the Medical Director and Nurse Practitioner were regularly present in the building for resident care, they did not participate in the required QAPI meetings. The facility's QAPI policy, effective since 2017, outlines the responsibility of the Administrator to ensure compliance with regulatory requirements, including the proper composition and functioning of the QAPI committee.