QAA Committee Lacked Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required members, specifically an administrator, owner, board member, or other individual in a leadership role, as mandated. Over a 15-month period, attendance records showed that the administrator attended only two QAA meetings, and there was no evidence that the owner, a board member, or another leadership designee attended any meetings. Interviews with the medical director and DON confirmed that the administrator was not routinely present at QAA or QAPI meetings, and the DON noted that the administrator had only recently attended a meeting after a prolonged absence. The QAA committee was otherwise comprised of department managers, the medical director, and the consultant pharmacist, but lacked consistent leadership representation. The facility's QAPI policy outlined that the governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program, including identifying and prioritizing problems, incorporating input from staff and residents, and ensuring corrective actions are effective. Despite these policy requirements, the facility did not provide evidence that leadership was actively involved in the QAA process during the review period, as required by regulation.