QAA Committee Failed to Meet Quarterly and Lacked Required Member Attendance
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to meet the regulatory requirement of convening at least quarterly with all required members present. Specifically, the committee did not hold a required quarterly Quality Assurance Performance Improvement (QAPI) meeting in April 2025. Additionally, attendance records and interviews confirmed that the Director of Nursing (DON) was absent from the January 2025 meeting, and the Administrator did not attend the June 2025 meeting. The facility's policy requires the Administrator, DON, Medical Director, and Infection Preventionist to serve on the committee and attend these meetings. During interviews and record reviews, the Administrator acknowledged the lapses in both meeting frequency and required attendance, confirming that the QAA committee did not meet in April and that key members missed other meetings. The Administrator also stated that the monitoring and documentation portion of the QAPI plan was not compiled or maintained in the facility's records, and recognized that these practices were not up to standard. No information about specific residents or their conditions was provided in the report.