QA&A Committee Lacked Required Quarterly Meetings and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) Committee that met at least quarterly with the required members in attendance. During the survey, the facility was only able to provide an attendance roster for one meeting, and could not produce documentation for other required meetings. Administrative staff confirmed that while meetings were being held monthly, the Medical Director only attended quarterly, and there was no attendance sheet available for the most recent meeting. The facility's own QAPI policy indicated that the committee should meet monthly to review reports, evaluate data, and monitor QAPI-related activities, but the lack of documentation and inconsistent attendance by required members led to the deficiency.