Failure to Hold Required Quarterly QAA Meetings
Penalty
No penalty information released
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 conduct quarterly Quality Assessment and Assurance (QAA) meetings as required by its QAPI Plan, which specifies that the committee must meet on a quarterly basis. Record review showed that only two QAA sign-in sheets were available for the past year, dated March and April, with no documentation of meetings prior to March. The administrator confirmed that QAA meetings were not held during her temporary absence starting in July, and no additional sign-in sheets could be located. This lapse in holding required QAA meetings has the potential to affect all 97 residents residing in the facility, as documented on the CMS form 671.