QAA Meetings Lacked Required Attendance
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of the four quarterly meetings in 2024. Specifically, the Medical Director did not attend the QAA meetings in the first and fourth quarters of 2024. This was confirmed through a review of the facility's Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records, as well as an interview with the Administrator on January 16, 2025, who acknowledged the Medical Director's absence from these meetings.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. No residents were identified to have been affected by this alleged deficient practice. NHA educated on the components of this regulation with emphasis on the need for the Medical Director to attend the QAPI Meetings. RDCS will audit QAPI sign in sheets to ensure Medical Director is present at least quarterly for QAPI meetings. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.