Failure to Hold and Document Required Quarterly Medical Staff/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA)/QAPI group, including the medical staff, met at least quarterly as required. During interviews and document review with the Administrator, surveyors learned that the facility’s Medical Director had been unavailable to come into the facility since 2/19/2026, and the only other physician on staff had retired at an unknown time in 2025 and had not been replaced. The Administrator was unable to produce any Medical Staff/QAPI meeting minutes or agendas for the prior 12 months and reported that the last Medical Staff/QAPI meeting occurred in September or October 2025, but she could not provide documentation to verify that it took place. She also stated that a Medical Staff/QAPI meeting had been planned for 2/26/2026 but did not occur because they did not have a quorum. No facility policy related to these meetings was provided for surveyor review despite request. No specific residents or their medical conditions were mentioned in the report, and no additional clinical details were provided regarding individual patient involvement in this deficiency.
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