Failure to Hold QAA Meeting with All Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of three quarterly meetings in Quarter One of 2025. According to the facility's QAPI Committee Charter policy, QAPI is intended to be a systematic and comprehensive process for monitoring performance and identifying improvement opportunities. However, a review of QAPI sign-in sheets and attendance records for the specified quarter showed that the Medical Director was not present at the meeting. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required QAA meeting did not include all mandated committee members as stipulated by facility policy and regulatory requirements.