Failure to Conduct QAA Meetings with Required Members
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 quarters in 2024. Specifically, the Medical Director was not in attendance during the QAA meetings from January to March 2024, and the Infection Preventionist was absent from the meetings held from July to September 2024. This deficiency was identified through a review of the facility's policy on Quality Assurance Performance Improvement (QAPI) and the QAPI Committee meeting sign-in sheets. The Director of Nursing confirmed during an interview that the facility did not meet the requirement of having all necessary committee members present at the quarterly QAA meetings. The facility's policy mandates that the QAA committee should include the Administrator, Director of Nursing, Physician, Pharmacy Consultant, and other staff members, including the Infection Preventionist, to ensure comprehensive quality assessment and improvement activities. The absence of key members, such as the Medical Director and Infection Preventionist, indicates a failure to comply with the regulatory requirements for maintaining an effective QAA committee.
Plan Of Correction
Infection preventionist reviewed QA data from Q3 of 2024. Medical director reviewed data from Q1 of 2024. An audit was done of QA attendance logs for 2024 to ensure all required persons were in attendance. Director of nursing or designee will in-service required persons for QA meeting on meeting schedule and required attendance. Director of nursing or designee will audit attendance sheets quarterly to ensure attendance of required persons. Audit findings will be shared with QAPI committee.