QA&A Committee Lacked Required Documentation of Medical Director Attendance
Penalty
No penalty information released
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 maintain a Quality Assessment and Assurance (QA&A) Committee with the required membership in attendance, as evidenced by the absence of the Medical Director's signature on the attendance roster for one of the quarterly meetings. Although the Administrative Nurse stated that the Medical Director was present at the meeting, there was no signed documentation to confirm this. Additionally, when requested, the facility was unable to provide a QA&A policy. These findings were based on a review of the QA&A committee attendance records and staff interviews, and involved a facility with a census of 44 residents and a sample of 12 residents.