QAA Committee Lacked Required Members and Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting attendance as specified by regulation. Record review showed that the QAA Committee did not consistently include the Infection Preventionist or the Medical Director or their designee at meetings from October 2024 to February 2025. Specifically, the Infection Preventionist was not present at any meetings during this period, and the Medical Director or designee was absent from the January and February 2025 meetings. Interviews revealed that the facility did not have a certified Infection Preventionist at the time of the survey due to a recent resignation, and the Medical Director had not attended meetings, with only occasional attendance by a medical provider serving as a designee. The facility's QAA and Performance Improvement Plan required these roles to be present, but documentation and staff statements confirmed that these requirements were not met during the review period.