Failure to Maintain Required QAA Committee Membership and Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required membership and meeting frequency. Specifically, the QAA committee did not have documented attendance from the medical director or their representative, the administrator or governance leadership, or the consultant pharmacist. Sign-in sheets were only available for two meetings in 2025, with no documentation for meetings in 2024. Administrative staff confirmed the absence of these records and were unable to locate them within the facility. Additionally, the facility did not initiate any Performance Improvement Projects (PIPs) during the current year and had no documentation of PIPs from the previous year. The facility's QAPI policy required a comprehensive, data-driven program with systematic identification and prevention of adverse events, and specified the required committee members and quarterly meetings. The lack of proper QAA committee function and documentation placed all 30 residents at risk for impaired care and services.