Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three out of four quarterly meetings in 2024. According to the facility's policy, the QAA committee is required to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. However, the review of the Quality Assurance attendance records indicated that the facility only held a first-quarter meeting on February 22, 2024, and did not provide evidence of conducting meetings for the second, third, and fourth quarters of 2024. During an interview, the Director of Nursing (DON) confirmed the facility's failure to conduct the required QAA meetings with all necessary committee members for the specified quarters. This deficiency was identified based on the facility's policy review, attendance records, and staff interviews, highlighting a lapse in maintaining the mandated schedule and composition of the QAA committee meetings.
Plan Of Correction
Facility determined that not having quarterly quality assurance meetings could negatively affect the residents. Administrator and Director of nursing will be educated and educate all managers on the importance of regularly scheduled quality assurance meetings by regional clinical nurse. Administrator or designee will audit compliance with the quality assurance meetings. Findings will be reported at the quality assurance meetings.