Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members and did not consistently hold meetings as outlined in their policy. According to the facility's December 2024 QAPI Committee policy, the committee was to meet monthly and include the Administrator, Director of Nursing Services, Medical Director, and an infection control representative. However, review of meeting sign-in sheets revealed repeated absences of key members, including the Medical Director, Director of Nursing, and Infection Preventionist, across multiple meetings. Additionally, there was no documentation of QAPI meetings for certain months, specifically December 2024 and March 2025. During an interview, the newly hired Administrator confirmed that QAPI meetings were expected to be held monthly and that all required committee members should attend. The Administrator was unable to account for the missing meetings and acknowledged the absence of key participants in several documented meetings. This lack of compliance with both facility policy and regulatory requirements resulted in the deficiency cited by surveyors.