QAA Committee Lacked Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met at least quarterly as required. Review of QAA committee meeting sign-in sheets for the past four quarters showed that the committee met on four occasions; however, the Director of Nursing (DON), who also served as the Infection Preventionist (IP), was absent from two of these meetings. This absence was confirmed by both documentation and staff interview with the Nursing Home Administrator (NHA), who verified that the DON/IP did not attend the meetings in question. As a result, the QAA committee did not meet with all required members for two of the four reviewed quarters, affecting the oversight of quality assessment and assurance processes for all 31 residents in the facility.