QAA Committee Lacked Required DON Member
Penalty
Fine: $148,11041 days payment denial
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 that the Director of Nursing (DON) was a member of the Quality Assessment and Assurance (QAA) Committee, as required by both facility policy and federal guidelines. Review of the QAA Committee attendance sheet for the most recent meeting showed that the attendees included the Administrator, Medical Director, Pharmacist, Medical Records consultant, and Assistant Director of Nursing (ADON), but not the DON. During an interview, the Administrator confirmed that the facility currently does not have a DON. The facility's QAPI policy specifies that the QAA Committee must include the DON, among other required members. This deficiency has the potential to affect all 46 residents currently residing in the facility.