Failure to Hold Required QAA Meetings with All Mandated Members
Penalty
Summary
The facility failed to hold required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated members present, as evidenced by a review of QAA meeting sign-in documentation, staff interviews, and facility policy. There was no documentation of QAA meetings for the first, second, and third quarters of 2024. For the fourth quarter of 2024, while a meeting was documented, there was no sign-in sheet to confirm the attendance of all required members. Additionally, meetings held in early 2025 were missing attendance from key members, including the Medical Director, Director of Nursing, and Infection Preventionist. The Administrator confirmed during an interview that there was no documentation of quarterly QAA meetings prior to the fourth quarter of 2024 and that not all required members were present for subsequent meetings. The facility's policy specifies that the QAA committee must include the administrator (or designee), director of nursing services, medical director, infection preventionist, and representatives from various departments as needed, and that meetings must occur at least quarterly. The lack of proper documentation and attendance had the potential to affect all residents, with a facility census of 57 at the time of the survey.