Medical Director's Absence in QAPI Meetings
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee included the Medical Director or their designee in quarterly meetings, as required by their policy. The facility's QAPI policy, last revised in 2022, mandates that the committee must consist of the director of nursing services, the medical director or designee, and at least one other member of the facility staff, with meetings held quarterly. However, a review of the Quarterly Meeting Attendance Sheets revealed that the Medical Director did not sign the attendance sheets for any of the four quarterly meetings in 2024, indicating a lack of participation. Interviews conducted during the survey revealed discrepancies in the Medical Director's involvement. The Director of Nursing stated that the Medical Director only attends quarterly meetings, while the Medical Director claimed to attend some meetings and be informed by the Administrator about the discussions. The Administrator confirmed that the Medical Director does not physically attend the quality assurance meetings but is briefed afterward. This lack of documented attendance and participation by the Medical Director in the QAPI and QAA meetings constitutes a deficiency in meeting the facility's policy requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò The Medical Director was in-serviced on 2/13/25 on the requirement to attend the QAPI meetings quarterly or designate a qualified representative in their absence. ò The Medical Director was instructed to sign the attendance sheet for all QAPI meetings to ensure proper documentation of participation on 2/13/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? ò The facility Policy and Procedure was titled QAPI, was reviewed and dated, no revision needed. ò An Audit tool is being developed to monitor the attendance of all QAPI committee members. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a quarterly basis for the one quarter, the Administrator, or designee, will monitor the attendance of all QAPI committee members to ensure compliance. ò Quarterly, the Administrator or designee will formally invite the Medical Director to the QAPI meetings. ò Quarterly for on the Administrator or designee will ensure the Medical Director attends each quarterly QAPI meeting, either in person or via Zoom. ò The Administrator or designee will verify and document the Medical Director’s attendance at each QAPI meeting. 5. The title of the person responsible for correction of each deficiency: Administrator
Penalty
Resources
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Surveyors found that the facility failed to conduct and document required QAPI activities, with no QAPI records for most of the review period and no active Performance Improvement Projects. The Assistant Administrator reported that current leadership could not locate prior QAPI documentation and that expected monthly QA and quarterly QAPI meetings were not evidenced. Review of maintenance, pest control, Resident Council, and grievance records showed that administration was aware of ongoing resident and family concerns that persisted without resolution. The survey also identified an ineffective staff training program on QAPI, communication, and behavioral health, and there was no documentation that the governing body was informed of or acting on the identified issues.
Surveyors found that the facility did not hold QAA/QAPI meetings on a quarterly basis and did not include the medical director as a participant. Review of meeting sign-in sheets and minutes showed that the medical director did not attend documented meetings, and the Administrator acknowledged that no QAPI meeting was held for one quarter and that the medical director had never attended these meetings. The Administrator also reported there was no written policy governing quarterly quality assurance meetings, despite an expectation that they occur quarterly with medical director involvement, affecting all residents in the facility.
The facility did not ensure its QAA committee met at least quarterly or maintained required membership. The written QAPI program and policy called for regular, at least monthly, QAA/QAPI meetings, but review of meeting minutes and sign-in sheets showed only four meetings over an extended period, with gaps of about four and five months between sessions. Attendance records also showed that no medical provider participated in one of the meetings. In an interview, the Administrator confirmed there were no additional QAA/QAPI meetings during the identified gap period, resulting in noncompliance with regulatory requirements for QAA committee frequency and composition.
QAPI committee meetings were not documented as held for two reviewed quarters, and the Medical Director or designated physician representative was not documented as attending the required quarterly QAPI meetings. The facility’s QAPI policy described the program as comprehensive and ongoing, but it did not specify physician participation or attendance expectations, and the DON and NHA acknowledged the missing documentation.
QAA Meeting Attendance Deficiency: The facility failed to ensure all required QAA members attended quarterly meetings. Review of QAPI attendance records showed the required team had not all attended a quarterly meeting since 5/27/25. The DON acknowledged that staff turnover, leadership changes, and the Infection Preventionist being pulled to work as a charge nurse affected attendance. The QAPI plan listed the required participants, including the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director, Activity Director, Social Worker, and Dietary Manager.
The facility failed to hold a required quarterly Quality Assessment and Assurance (QAA) committee meeting for one quarter, despite federal regulations and its own QAPI policy requiring at least quarterly meetings. Review of QAPI sign-in sheets and attendance records for the fourth quarter of the year showed no evidence that a QAA meeting occurred, and the Nursing Home Administrator confirmed that the committee did not meet with all required members during that quarter, including leadership and the infection preventionist.
Failure to Conduct and Document Required QAPI Activities and Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program met regulatory requirements, including conducting QAPI meetings at least quarterly and maintaining documentation of QAPI activities. Surveyors reviewing four quarters of records found no QAPI documentation for three of the four quarters in 2025, with only one quarter in 2026 having documentation. The Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but there was no current Performance Improvement Project in place. During the survey, which was extended after substandard quality of care was identified, surveyors reviewed maintenance logs, pest control logs, Resident Council minutes, and grievance logs. These records showed that administration was aware of ongoing issues and concerns voiced by residents and families that continued for several months without resolution. The survey also determined that the facility did not have an effective training program, including required training on QAPI, effective communication, and behavioral health. Despite the identification of substandard quality of care and other issues by the survey team, there was no documentation that the governing body was aware of or acting on these findings.
Failure to Hold Quarterly QAA/QAPI Meetings With Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA)/QAPI program met regulatory requirements for quarterly meetings and required membership. Review of Quality Assurance meeting sign-in sheets and minutes dated 1/23/25, 3/13/25, 7/30/25, and 1/9/26 showed no signature from the facility’s medical director, indicating the medical director did not attend these meetings. In an interview on 3/24/26 at 11:20 AM, the Administrator (V1) stated that a QAPI meeting was not held for the 4th quarter of 2025 and that meetings were only held in January, March, and July of 2025. V1 further stated that the medical director had never attended the QAPI meetings. On 4/13/26 at 3:00 PM, V1 confirmed there was no facility policy related to quarterly quality assurance meetings, but acknowledged that meetings were supposed to be held quarterly and that the medical director should be in attendance. The facility’s daily census report dated 3/17/26 documented that 67 residents were residing in the facility at the time of the survey. No additional resident-specific medical histories or conditions were described in the report beyond the total number of residents potentially affected.
Failure to Hold Quarterly QAA Meetings With Required Membership
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. The facility’s Quality Assurance and Performance Improvement (QAPI) Program, reviewed on 04/28/2025, outlined a purpose focused on continuous evaluation of facility systems, ensuring care delivery systems function consistently and accurately, preventing deviations from care processes, identifying issues and opportunities for improvement, and developing and implementing plans to correct identified areas. The facility’s QAPI Committee policy, last reviewed in December 2022, specified that the committee would meet monthly at an appointed time, with special meetings called as needed. Review of QAPI meeting minutes and sign-in sheets showed meetings held on 05/29/2025, 09/26/2025, 10/31/2025, and 03/24/2026, revealing an approximate five-month lapse between the 10/31/2025 and 03/24/2026 meetings, and an approximate four-month interval between the 05/29/2025 and 09/26/2025 meetings. Further review of attendance records showed that no medical provider attended the 03/24/2026 meeting. During an interview on 04/22/2026, the Administrator, who had been in the role since February 2026, confirmed that a QAPI meeting was held at the end of March 2026 and did not identify any additional meetings between October 2025 and March 2026. These findings demonstrate that the QAA committee did not meet at least quarterly and lacked required membership at one meeting, in violation of Title 10 NYCRR 415.27(c)(1).
QAPI Committee Meetings and Physician Participation Not Documented
Penalty
Summary
The facility failed to ensure that required quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were conducted and failed to ensure the Medical Director or a physician designated by the Medical Director attended the required quarterly QAPI meetings for two of four quarters reviewed, specifically Quarters 3 and 4 of 2025. Facility documentation showed the QAPI policy, last reviewed May 1, 2025, described a comprehensive, ongoing program to review data and care practices, but it did not specify required participation by the Medical Director or a designated physician and did not outline expectations for attendance or accountability at quarterly QAPI meetings. A review of available QAPI committee meeting sign-in sheets and supporting documentation showed the facility could not provide evidence that required quarterly QAPI committee meetings were held during August 2025 through December 2025. The facility also could not provide documentation that the Medical Director or a designated physician representative attended QAPI meetings during July 2025 through December 2025. During an interview on April 17, 2026, the DON and NHA acknowledged the facility was unable to provide documentation supporting the required quarterly meetings and acknowledged that the Medical Director or designated physician representative had not attended the identified QAPI meetings.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Review of QAPI meeting attendance sign-in sheets from March 2025 through April 2026 showed that all required team members had not attended a quarterly QAA meeting since 5/27/25. During an interview on 4/15/26 at 12:40 PM, the DON acknowledged that not all required team members had attended the QAA meeting quarterly and stated that staff turnover and leadership changes had affected attendance. She also said the Infection Preventionist had sometimes been required to work on the floor as a charge nurse and therefore had not always been able to attend the meetings. The facility’s QAPI Plan, updated 3/1/26, stated the facility would meet monthly to discuss ongoing or new issues in the nursing home, and identified the required participants as the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director at minimum every 3 months, Activity Director, Social Worker, and Dietary Manager.
Failure to Hold Required Quarterly QAA Committee Meeting
Penalty
Summary
The deficiency involves the facility’s failure to conduct required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated committee members. Federal regulations require that the QAA committee include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including an individual in a leadership role such as the administrator, and the infection preventionist (IP), and that this committee meet at least quarterly to coordinate and evaluate activities under the QAPI program. The facility’s own “Quality Assurance and Performance Improvement (QAPI)” policy, dated 1/5/26, states that the QAPI program is an ongoing comprehensive program addressing all systems of care and that meetings are to occur at least quarterly, monthly, or more often if needed. Surveyors reviewed QAPI sign-in sheets and attendance records for Quarter Four of 2025 and did not find evidence that a QAA meeting was held during that quarter as required. During an interview on 4/10/26 at 10:40 a.m., the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members for one of the four quarterly meetings, specifically Quarter Four of 2025. No resident-specific information, medical histories, or clinical conditions were described in relation to this deficiency.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026. A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation.
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