QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Performance Improvement Committee (QAPI) was composed of the minimum required members for three out of five meetings during the year. Specifically, review of the QAPI meeting attendance/sign-in sheets for the dates provided showed that the Infection Preventionist did not attend the meetings on three occasions. Additionally, there was no sign-in sheet available for one of the required quarterly meetings, indicating a lack of documentation for that meeting. During interviews, the Director of Nursing confirmed the typical attendees of the QAPI meetings and acknowledged that the Infection Preventionist was not always present, sometimes due to other duties. The facility's own policy requires the Infection Preventionist, along with other specified staff, to be part of the QAPI committee. No further information or documentation was provided by facility staff to address the absence of the Infection Preventionist or the missing meeting documentation.