F0868

D

Failure to Ensure Infection Preventionist Participation in QAPI Meetings

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

Facility staff failed to ensure that the Infection Preventionist (IP) was in attendance at the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Record review of QAPI committee meeting sign-in sheets for the period from March 2025 through December 2025 showed that an IP had not attended the meetings on at least a quarterly basis, with 5 of 10 meetings reviewed lacking IP attendance. During an interview, the Corporate Clinical Resource Nurse, who was acting as the Quality Assurance coordinator and IP, stated that the facility had not had a staff member formally assigned as an IP for the past 10 months.

This lack of an assigned IP and the resulting failure to have the IP present at QAPI meetings led to noncompliance with the requirement that the Quality Assessment and Assurance group include the required members and meet at least quarterly with appropriate representation.