QAA Committee Failed to Meet Quarterly as Required
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. Record review and interview with the Registered Nurse Manager (RNM) revealed that the QAA committee only met three times over a twelve-month period, with meeting dates documented as 1/20/25, 9/12/24, and 5/23/24. The RNM confirmed these were the only meetings held during the past year and acknowledged that the committee did not meet quarterly. Additionally, review of the facility's Quality Assurance and Performance Improvement Plan policy did not specify the required frequency for QAA committee meetings.