Failure to Maintain Ongoing QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain and implement an ongoing Quality Assurance and Performance Improvement (QAPI) program as required. Documentation and evidence of QAPI activities, committee meetings, or performance improvement projects were not available for review since 07/17/2025. The last recorded meeting of the Quality Assurance (QA) committee was on that date, and no subsequent meetings or activities were documented. During an interview, the Administrator confirmed that the QA committee was expected to meet monthly to review concerns, discuss current issues, and revise care plans as needed, but acknowledged that no meetings had occurred since the last documented date. A review of the facility's QAPI policy and procedure indicated that the facility was required to develop, implement, and maintain an ongoing, facility-wide QAPI plan, with the QA committee meeting monthly to monitor and evaluate the quality and safety of resident care. The policy outlined objectives such as identifying and resolving negative outcomes, correcting deficiencies, and maintaining documentation of QAPI activities. The lack of ongoing QAPI activities and documentation demonstrated noncompliance with the facility's own policy and regulatory requirements.