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Senior Living Liability
ComplianceStandard / Universal

Peer Review and QAPI Privilege

What this clause says

The records and proceedings of the quality assessment and assurance committee are confidential and are not subject to discovery in a civil action, except as otherwise provided by law.

What this actually means

Most states protect the deliberations of a quality assurance or peer review committee from civil discovery, and federal law restricts disclosure of the records of a facility quality assessment and assurance committee to surveyors. The protection covers the committee analysis, not the underlying facts.

What it means for an operator

A plaintiff cannot obtain the committee analysis of a fall cluster but can obtain every incident report, chart and staffing record the committee reviewed, from their original sources. Running facts through a committee does not launder them. The protection is also routinely lost through handling: mixing operational documents into committee packets, circulating minutes to regional management or an owner, using committee findings to support a disciplinary action, or never constituting the committee formally in the first place. Keep the committee constituted as the regulation requires, keep its material in a separate restricted repository, keep minutes deliberative rather than narrative, and keep the operational corrective action separate from the analysis that produced it. And do the work regardless, because a facility with no documented quality analysis faces a worse allegation than one whose analysis is eventually produced.

Why the Policy Checker does not score this

This term is worth understanding and cannot be checked from a declarations page. There is no single field that would answer it, and scoring it from an assumption would produce a confident wrong finding, which is the one thing a tool like this must never do. It is defined here and left out of the check.

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