Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of the four quarters, specifically from January 2024 through March 2024. The facility's policy on Quality Assurance and Performance Improvement (QAPI) requires the QAA committee to include the Administrator, Director of Nursing Services, Medical Director or designee, Infection Preventionist, direct care staff on a rotating basis, staff from ancillary departments on a rotating basis, and at least two other members of the facility staff. However, a review of the QAPI Committee meeting sign-in sheets for the specified period revealed that the Nursing Home Administrator was not in attendance. During an interview, the Nursing Home Administrator confirmed the facility's failure to conduct QAA meetings with all required committee members as mandated. This deficiency was identified based on the review of facility policy, Quality Assurance attendance records, and staff interviews, indicating non-compliance with the regulatory requirements for maintaining a comprehensive QAA committee.
Plan Of Correction
All required attendees failed to attend the Quality Assurance Performance Improvement committee meeting. Facility is unable to retroactively correct this citation. Moving forward the facility will maintain Quality Assurance Performance Improvement (QAPI) committee according to the regulation. To prevent this from happening again the RVPO/designee educated the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained. To monitor and maintain ongoing compliance the RVPO/designee will audit Quarterly x3 to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained.