Failure to Hold Quarterly QAA Meetings with Required Members
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 its Quality Assessment and Assurance (QAA) Committee met at least quarterly and included all required members, as specified in its own policy. Review of QAA Committee meeting minutes revealed that the committee did not meet during two of the five reviewed quarters, specifically in June and September of 2024. Additionally, the medical director did not attend any of the QAA Committee meetings during the review period. An administrative staff member confirmed that the committee had not met on a quarterly basis and that the medical director's required attendance was not ensured.