QAA Committee Lacked Required Medical Director Participation
Penalty
Fine: $26,685
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 ensure that the Quality Assessment and Assurance (QAA) committee included all required members, specifically the Medical Director (MD), for a census of 45 residents. During a review of the facility's quarterly Quality Assurance and Performance Improvement (QAPI) meeting records, it was confirmed by the Administrator that the MD did not attend the QAPI meeting held in April 2024. The sign-in sheet for the meeting did not include the MD's name or signature, despite facility documentation and policy indicating that the MD is a required member of the QAA committee.