Lack of Medical Director Participation in QAPI Committee
Penalty
Summary
The facility failed to include a Medical Director as a required member of the Quality Assurance Performance Improvement (QAPI) committee, resulting in noncompliance with the requirement that the Quality Assessment and Assurance group have the required members and meet at least quarterly. Review of QAPI documentation from July 2025 through January 2026 showed no Medical Director attendance at QAPI meetings during that period. The facility’s QAPI plan states that the program is to be an ongoing, facility-wide plan to monitor and evaluate the quality and safety of resident care, resolve identified problems, and coordinate quality-related activities across departments and services. Interviews with facility leadership confirmed that the Medical Director position had been vacant since approximately June or July 2025, when the former Medical Director retired, and that no replacement had been appointed. The DON reported that she was the only person reviewing clinical trends and participating in QAPI clinical review during this time. The Administrator stated that the former Medical Director had been a quarterly attendee at QAPI and last attended in June 2025, and acknowledged that this was the second quarter without a Medical Director participating. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were being achieved since the Medical Director position became vacant. All 52 residents residing in the facility were subject to this deficient practice.
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