Failure to Implement Effective Governing Body Communication and QAPI Involvement
Penalty
Summary
The facility failed to establish and implement a process for communication between the administrator and the governing body, including the mode of communication, frequency, and content of what was to be communicated. Review of the Governing Body Policy and Procedure showed no implementation date and stated that governing body members were to be active, engaged, involved in facility affairs, have direct access to the administrator and compliance officer through executive board sessions, and be involved in the QAPI program. A letter designated the administrator as the Compliance and Ethics Officer and identified the DON, social worker, and medical director as members of the Compliance and Ethics Committee. However, review of QAPI meeting sign-in sheets showed no evidence that any governing body member attended these meetings. In an interview, the NHA stated she was not aware of a policy regarding governing body involvement with the facility, reported that governing body members had not attended QAPI meetings, and acknowledged she had not contacted them since her return to the facility.
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