Failure to Conduct Required 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 of four quarters in 2024. Specifically, the facility did not have the QAPI Committee meeting sign-in sheets available for the period from April 2024 through June 2024. Additionally, the review of the QAPI Committee meeting sign-in sheets from July 2024 through December 2024 revealed that the Infection Preventionist was not in attendance. During an interview, the Nursing Home Administrator and Director of Nursing 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.
Plan Of Correction
1. Facility has since had an Infection Preventionist to attend next QAPI meeting. 2. NHA will receive education from Vice President of Operations on QAPI attendees. 3. NHA will educate all required attendees of QAPI-on-QAPI attendance requirements. 4. NHA to audit QAPI attendees for all required attendees for 2 quarters. 5. Results to be submitted to QAPI for review and approval.