QAA Committee Lacked Required Members at Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members present at each meeting for the first quarter of 2025. Record review of QAPI committee meeting sign-in sheets showed that the Medical Director and Infection Preventionist (IP) were not in attendance at meetings held in January and February, and the Director of Nursing (DON) and IP were not present at the March meeting. The facility's QAPI plan specifies that the committee must include, at a minimum, the DON, Medical Director or designee, at least three other staff members (including at least one in a leadership role), and the IP. During an interview, the Administrator acknowledged difficulties in scheduling but expected all required staff to attend. The facility had a reported census of 51 residents at the time.