Failure to Hold Required QAA Meetings and Include Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee met at least quarterly and included the required members, such as the administrator, owner, board member, or designee. According to interviews and record reviews, the Skilled Nursing Unit (SNU) had not held QAA committee meetings for the past three quarters due to the absence of an administrator to oversee the process. The Compliance Officer reported discussing QAPI at the hospital level and offered to chair the committee in the future, but this had not yet occurred. When the Medical Director was on leave, the covering physician discovered the lack of QAPI meetings and called for one, but prior to that, no meetings had been held. Additionally, the QAPI agenda for the most recent meeting did not list any QAA committee members.