Failure to Maintain Required QAA Committee Membership and Meeting Attendance
Penalty
Summary
Facility staff failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required members, specifically the Medical Director and an Infection Preventionist. Review of QAPI (Quality Assurance Performance Improvement) committee meeting attendance sheets from April 2024 through April 2025 revealed that the Infection Preventionist was absent from multiple meetings, including several quarterly meetings, and the Medical Director was also absent from several meetings. Additionally, there was no evidence that meetings were held in certain months, as no sign-in sheets or documentation were available for those periods. Further review indicated that although the current Infection Preventionist had recently assumed the role, neither the current nor former Infection Preventionists attended the required meetings in that capacity. The staff member who is now the Infection Preventionist was present at some meetings, but only in the role of an MDS nurse, not as the Infection Preventionist. The absence of these key committee members was confirmed through record review and staff interviews.