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F0868
D

Required QAPI Committee Members Absent from Quarterly Meeting

Palmyra, Pennsylvania Survey Completed on 03-05-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement (QAPI) committee attended a quarterly meeting, as required by regulation. Review of the QAPI committee minutes for the meeting held on February 18, 2026, showed that the Director of Nursing (DON) and the Medical Director were not present. During an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there was no documented evidence that the DON and Medical Director attended that QAPI meeting. This deficiency was cited under 42 CFR 483.75(g) for quality assessment and assurance and 28 Pa. Code 201.18(e)(1)(2)(3) related to management. No residents or specific clinical events were referenced in the report, and the deficiency is based solely on documentation review and staff interview regarding required QAPI committee membership and attendance.

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