QA&A Committee Lacked Required Medical Director Documentation
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 committee attendance roster for meetings held over a one-year period. Although administrative staff reported that the Medical Director participated in the meetings via an audio-visual conferencing device, there was no documented evidence of their attendance on the official roster. The facility's policy requires the Medical Director, along with other key staff and representatives, to be present at these meetings. This deficiency was identified through review of the QA&A committee attendance records and staff interviews.