Failure to Ensure Required QAA Committee Members Present at Quarterly Meeting
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members present, as evidenced by a review of facility policy, QAA attendance records, and staff interviews. Specifically, for the first quarter of 2025, the attendance records did not show that the Infection Preventionist was present at the QAA meeting. This was confirmed by the Director of Nursing during an interview, who acknowledged that the required quarterly meeting did not include all mandated committee members for that quarter. The facility's QAPI policy requires an ongoing, facility-wide, data-driven program focused on care outcomes and quality of life, and mandates quarterly QAA meetings with specific committee members, including the Infection Preventionist. The absence of the Infection Preventionist at the required meeting constituted noncompliance with both facility policy and regulatory requirements.