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F0868
F

Infection Preventionist Absent from QAPI Committee Meetings

Woodstock, Virginia Survey Completed on 09-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that the required Infection Preventionist attended the Quality Assurance and Performance Improvement (QAPI) committee meetings for three consecutive quarters, covering the periods from October 2024 through June 2025. Review of QAPI meeting sign-in sheets for these quarters did not show the signature of an Infection Preventionist, as required by facility policy. During interviews, the executive director confirmed that an Infection Preventionist was supposed to attend these meetings and acknowledged that there was no documentation to show their attendance during the specified timeframes. The facility's policy states that the QAPI committee must be interdisciplinary and include, at a minimum, the Infection Preventionist, and must meet at least quarterly.

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