QAA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the required members, specifically the Medical Director, during its quarterly meetings. Record review and interviews with the Administrator revealed that the Medical Director did not attend three consecutive quarterly QAA committee meetings. Sign-in sheets for the meetings confirmed the absence of the Medical Director or a designee, and the Administrator acknowledged that the Medical Director was not always present at these meetings. Facility documents also indicated that the Medical Director was a required member of the QAA committee, but attendance records did not reflect their participation. The Administrator stated that the QAA committee, which also functioned as the Continuous Quality Improvement (CQI) committee, met regularly to address ongoing issues such as resident falls and urinary tract infections. However, the lack of the Medical Director's attendance meant that they were not informed of or involved in oversight activities, including identifying, analyzing, and correcting problems in resident care policies and areas. The Administrator recognized the importance of the Medical Director's involvement in these meetings, as they are responsible for the physicians and the management of resident care within the facility.