Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting frequency as outlined in its own policy and federal regulations. Specifically, the QAA Committee did not consistently include the Medical Director, who is a required member, during meetings held in June 2024 and July 2025. Additionally, the committee did not meet at least quarterly as required, with two meetings over the last four quarters not occurring within the appropriate timeframe. Review of sign-in sheets confirmed the absence of the Medical Director at the specified meetings, and there was no documentation to support that the Medical Director was informed of the meeting content in a manner consistent with policy requirements. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging both the absence of the Medical Director at the required meetings and the failure to meet the quarterly meeting schedule. The facility's QAPI policy specifies the necessary committee members and meeting frequency, but records and interviews demonstrated that these requirements were not met. This deficiency has the potential to affect all 48 residents residing in the facility.