Facility Assessment Lacked Required Review and Approval
Penalty
Summary
The facility failed to ensure that the Facility Assessment (FA) was properly reviewed, updated, and approved by the required facility leadership and management, including the Quality Assessment and Assurance (QAA) Committee. The FA dated 03/25/2025, which was presented by the Interim Executive Director (IED), did not include documented evidence of review or approval by the QAA Committee, nor did it have an attendance sheet indicating participation from the necessary leadership members. The IED confirmed that the FA was created and implemented solely by themselves without input or review from other required members of facility leadership or management. Additionally, the facility did not have a policy or procedure in place regarding the review, updating, or implementation of the FA, nor did it specify the required attendees for such processes. The previous FA, dated 08/29/2024, did include an attendance sheet with various facility leaders, but the IED stated that this version was considered null and void. The lack of proper review and approval processes for the FA was acknowledged by the IED, who admitted that the 03/25/2025 FA did not meet federal regulations and requirements.