QAA Committee Lacked Required Members and Attendance at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee was composed of all required members and met at least quarterly, as outlined in its own policy and procedure. According to the facility's policy, the QAA committee should include the Medical Director (MD), the Administrator, the Director of Nursing (DON), and three other staff members designated by the facility. Review of the QAA meeting minutes and sign-in sheets for three separate quarterly meetings revealed that the required composition of the committee was not consistently met. On one occasion, only the DON, Administrator, Dietary Manager, and MD were present, with no evidence of additional staff. On another occasion, the MD and Administrator were absent, and on a third occasion, only the DON, Administrator, and MD were present, again lacking additional staff members. The facility was unable to provide any additional documentation to demonstrate that the required members attended the QAA meetings on the reviewed dates. An interview with the DON confirmed that no further evidence was available to show compliance with the committee composition requirements for those meetings. No information about residents or their medical conditions was included in the report.