QAA Committee Lacked Required Members and Accurate Attendance 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 ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met the federal requirements for attendance documentation. Record review of QAA attendance sheets revealed inconsistencies, including missing signatures for the Infection Preventionist (IP) at several meetings and unclear documentation of who attended on multiple dates. The attendance sheets also incorrectly listed the federal requirements for committee membership, omitting the IP. During an interview, the Administrator acknowledged issues with the attendance system and confirmed that the documentation did not clearly indicate who was present at the meetings.