Failure to Ensure Required QAA Committee Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAA) Committee attended the quarterly meetings, as mandated by federal regulations. Specifically, review of the QAA Committee attendance records for the first quarter of 2025 revealed that the Medical Director did not attend any of the meetings. This was confirmed through an interview with the Director of Nursing, who acknowledged the Medical Director's absence from all QAA Committee meetings during this period. The facility's policy, dated March 12, 2025, states that the QAA Committee meetings are to be held at least quarterly and must include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director. Despite this policy, the required participation of the Medical Director was not met, resulting in noncompliance with both federal and state regulations regarding the composition and functioning of the QAA Committee.
Plan Of Correction
Director of Nursing reviewed the Quality Assessment and Assurance Committee Meeting minutes from the first quarter of 2025 with the facility's new Medical Director. Current facility residents have the ability to be affected by this alleged deficient practice. Nursing Home Administrator educated the new facility Medical Director of the requirement to attend the Quality Assessment and Assurance Committee Meetings on at least a quarterly basis and provided the date of the next upcoming scheduled Quality Assurance Committee Meeting. Nursing Home Administrator will audit attendance of members of the Quality Assessment and Assurance Committee Meetings to ensure the Medical Director attends at least on a quarterly basis monthly times six months until resolved. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times six for results, areas of improvement and/or continuation of audits.