QAA Committee Lacks Required Medical Director Participation
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required composition and frequency as mandated by regulations. Specifically, the QAA committee did not include the Medical Director as a participating member, which is a requirement. The committee was composed of the Administrator, Director of Nursing (DON), Therapeutic Recreation Specialist (TRS), Resident Advocate (RA), Maintenance Director, Business Office Manager, and Dietary Manager. However, there was no evidence that the Medical Director participated in the quarterly Quality Assurance and Performance Improvement (QAPI) meetings, as required by the facility's 2024 QAPI Plan. During an interview, the Administrator confirmed that the QAA committee met quarterly and as needed, but the Medical Director's attendance was inconsistent. The Administrator stated that the Medical Director was invited to the meetings but often did not attend due to scheduling conflicts, and instead, the Medical Director was typically followed up with meeting notes. The Administrator was unsure if the Medical Director attended the March 2024 meeting and confirmed that he did not attend the June 2024 meeting. This lack of participation by the Medical Director in the QAPI meetings is a deficiency in meeting the regulatory requirements for the QAA committee's composition and function.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to hold a required quarterly Quality Assessment and Assurance (QAA) committee meeting for one quarter, despite federal regulations and its own QAPI policy requiring at least quarterly meetings. Review of QAPI sign-in sheets and attendance records for the fourth quarter of the year showed no evidence that a QAA meeting occurred, and the Nursing Home Administrator confirmed that the committee did not meet with all required members during that quarter, including leadership and the infection preventionist.
The facility did not hold required Quality Assessment and Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly as mandated by its QAPI policy and state regulations. Policy required the QAA committee to meet at least quarterly to coordinate and evaluate QAPI activities, but review of QAPI sign-in sheets and attendance records showed no documented meetings for two consecutive quarters. In an interview, the Administrator confirmed that the required quarterly QAA meetings were not conducted during those periods.
Surveyors determined that the facility did not ensure all required members attended a quarterly QAPI meeting. Review of QAPI minutes showed that the DON and the Medical Director were not present at one of the two reviewed quarterly meetings, and the Regional Clinical Director confirmed there was no documentation of their attendance. This failure to include required leadership in the QAPI meeting was cited under federal quality assessment and assurance regulations and related state management requirements.
The facility failed to ensure its QAA/QAPI group, including medical staff, met at least quarterly and maintained required documentation. The Medical Director had been unavailable to come into the facility for an extended period, and the only other physician had retired and was not replaced. The Administrator could not provide Medical Staff/QAPI meeting minutes or agendas for the previous year and could only recall an undocumented meeting several months earlier. A more recent planned Medical Staff/QAPI meeting did not occur due to lack of quorum, and no related facility policy was produced for surveyor review.
The facility did not include a Medical Director on its QAPI committee after the prior Medical Director retired, leaving the position vacant for at least two consecutive quarters. QAPI records showed no Medical Director attendance during this period, and the DON reported being the only person reviewing clinical trends and participating in QAPI clinical review. The Administrator confirmed that the former Medical Director had been a quarterly QAPI attendee and acknowledged uncertainty about how physician-level oversight and regulatory compliance were maintained in the absence of a Medical Director, affecting all residents in the facility.
The facility failed to ensure the medical director attended and meaningfully participated in QAA meetings at least quarterly as required. The administrator reported that the QAA committee meets monthly and that she routinely texted the medical director reminders; he usually replied with topics for discussion and only occasionally joined by phone. Documentation showed the medical director attended one meeting in person and one by telephone during the review period, while for all other months he either did not attend or only sent topics via text. Facility policy identified the medical director as a QAA committee member and required the committee to meet at least quarterly.
Failure to Hold Required Quarterly QAA Committee Meeting
Penalty
Summary
The deficiency involves the facility’s failure to conduct required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated committee members. Federal regulations require that the QAA committee include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including an individual in a leadership role such as the administrator, and the infection preventionist (IP), and that this committee meet at least quarterly to coordinate and evaluate activities under the QAPI program. The facility’s own “Quality Assurance and Performance Improvement (QAPI)” policy, dated 1/5/26, states that the QAPI program is an ongoing comprehensive program addressing all systems of care and that meetings are to occur at least quarterly, monthly, or more often if needed. Surveyors reviewed QAPI sign-in sheets and attendance records for Quarter Four of 2025 and did not find evidence that a QAA meeting was held during that quarter as required. During an interview on 4/10/26 at 10:40 a.m., the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members for one of the four quarterly meetings, specifically Quarter Four of 2025. No resident-specific information, medical histories, or clinical conditions were described in relation to this deficiency.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026. A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation.
Failure to Hold Required Quarterly QAA/QAPI Committee Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required by its own Quality Assurance and Performance Improvement (QAPI) Program policy and state regulation. The written QAPI policy dated 8/15/25 stated that the QAA Committee, responsible for both QA and PI activities, would meet on a regular basis at least quarterly to coordinate and evaluate QAPI activities. Review of QAPI sign-in sheets and attendance records showed no documentation that QAA/QAPI meetings were held for the second and third quarters of 2025. During an interview, the Administrator confirmed that the facility did not conduct the required quarterly QAA meetings for those two quarters. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the facility’s failure to hold and document the mandated QAA Committee meetings in accordance with its policy and 28 Pa Code 201.18(e)(1)-(4).
Required QAPI Committee Members Absent from Quarterly Meeting
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement (QAPI) committee attended a quarterly meeting, as required by regulation. Review of the QAPI committee minutes for the meeting held on February 18, 2026, showed that the Director of Nursing (DON) and the Medical Director were not present. During an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there was no documented evidence that the DON and Medical Director attended that QAPI meeting. This deficiency was cited under 42 CFR 483.75(g) for quality assessment and assurance and 28 Pa. Code 201.18(e)(1)(2)(3) related to management. No residents or specific clinical events were referenced in the report, and the deficiency is based solely on documentation review and staff interview regarding required QAPI committee membership and attendance.
Failure to Hold and Document Required Quarterly Medical Staff/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA)/QAPI group, including the medical staff, met at least quarterly as required. During interviews and document review with the Administrator, surveyors learned that the facility’s Medical Director had been unavailable to come into the facility since 2/19/2026, and the only other physician on staff had retired at an unknown time in 2025 and had not been replaced. The Administrator was unable to produce any Medical Staff/QAPI meeting minutes or agendas for the prior 12 months and reported that the last Medical Staff/QAPI meeting occurred in September or October 2025, but she could not provide documentation to verify that it took place. She also stated that a Medical Staff/QAPI meeting had been planned for 2/26/2026 but did not occur because they did not have a quorum. No facility policy related to these meetings was provided for surveyor review despite request. No specific residents or their medical conditions were mentioned in the report, and no additional clinical details were provided regarding individual patient involvement in this deficiency.
Lack of Medical Director Participation in QAPI Committee
Penalty
Summary
The facility failed to include a Medical Director as a required member of the Quality Assurance Performance Improvement (QAPI) committee, resulting in noncompliance with the requirement that the Quality Assessment and Assurance group have the required members and meet at least quarterly. Review of QAPI documentation from July 2025 through January 2026 showed no Medical Director attendance at QAPI meetings during that period. The facility’s QAPI plan states that the program is to be an ongoing, facility-wide plan to monitor and evaluate the quality and safety of resident care, resolve identified problems, and coordinate quality-related activities across departments and services. Interviews with facility leadership confirmed that the Medical Director position had been vacant since approximately June or July 2025, when the former Medical Director retired, and that no replacement had been appointed. The DON reported that she was the only person reviewing clinical trends and participating in QAPI clinical review during this time. The Administrator stated that the former Medical Director had been a quarterly attendee at QAPI and last attended in June 2025, and acknowledged that this was the second quarter without a Medical Director participating. The Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were being achieved since the Medical Director position became vacant. All 52 residents residing in the facility were subject to this deficient practice.
Failure of Medical Director to Attend QAA Meetings at Least Quarterly
Penalty
Summary
The deficiency involves the facility’s failure to ensure the medical director attended and meaningfully participated in Quality Assessment and Assurance (QAA) committee meetings at least quarterly as required. During an interview, the administrator stated that the QAA committee meets monthly and that she texted the medical director each month to remind him of the meetings; he typically responded by texting topics for the committee to discuss and only sometimes attended by telephone. The administrator acknowledged she was aware that the medical director was required to attend at least quarterly and that he did not have a NP or PA to attend in his absence. Review of the QAA committee binder showed the medical director attended via telephone at the most recent meeting in late January 2026 and attended in person in mid-August 2025, but for all other months in 2025 he either did not attend or only sent texted topics instead of participating in the meetings. Review of the facility’s QAPI policy from July 2025 confirmed that the medical director was designated as a QAA committee member and that the committee was required to meet at least quarterly.
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