QAA Committee Lacked Required Participants at Quarterly Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required participants for two out of four quarters reviewed. Specifically, review of the QAPI binder for 2024 and 2025 revealed that the QAA meetings held on 3/26/25 and 10/2/24 did not have the Medical Director present, and the 3/26/25 meeting also lacked attendance by the Administrator or Board member. Documentation and interviews confirmed that the Medical Director was not present at these meetings, and there was no proof of attendance for the required participants. The facility's QAPI committee membership list otherwise met the minimal regulatory requirements, and meetings were held at least quarterly. However, the absence of the Medical Director and Administrator/Board member at the specified meetings resulted in noncompliance with participation requirements. This deficiency was identified through record review and interviews with facility staff, including the Interim Assistant Director of Nursing and Interim Director of Nursing.