Lack of Documentation for QA Meeting in First Quarter
Penalty
Summary
The facility failed to provide evidence that a Quality Assurance (QA) Committee meeting was held during the first quarter of 2024. This deficiency was identified through a review of facility documentation and staff interviews. The Nursing Home Administrator (NHA) stated that the meeting was conducted by the prior administration, but she did not receive the sign-in sheet or any documentation confirming the meeting took place. Despite follow-up inquiries, the NHA was unable to provide any evidence of the meeting, confirming the lack of documentation for the first quarter of 2024.
Plan Of Correction
1. The facility was unable to find quarter 1 signature sheet for QAA meeting. 2. The facility has conducted monthly QAA meetings since April of 2024. Signature sheets were available for review. An audit of these signature sheets was completed to ensure that meetings were conducted monthly. 3. Education was provided to the QAA committee on the importance of conducting QAA meetings as scheduled. 4. QAA meeting will be audited monthly x 2 by NHA or designee. The results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.