Failure to Hold Quarterly QAA Meetings and Ensure Infection Preventionist Participation
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 ensure that the Quality Assurance and Assessment (QAA) committee met at least quarterly, as required. Review of the QAA meeting sign-in sheets showed that the most recent meeting occurred on 04/09/2025, with the previous meeting on 10/09/2024, and no documentation was provided to show a QAA meeting was held during the first quarter of 2025. Additionally, the Infection Preventionist (IP) was not documented as attending the 04/09/2025 QAA meeting, and the Director of Nursing confirmed in an interview that the IP did not attend and that the committee did not meet during the required timeframe.