QAA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee met the regulatory requirements for membership and meeting frequency. Specifically, the Medical Director or a designated representative did not attend any of the 11 QAA meetings reviewed, as evidenced by sign-in sheets for each meeting date. The Administrator acknowledged that it was his responsibility to follow up with the Medical Director to ensure attendance, but stated that the Medical Director rarely attended despite being notified of meeting dates and times. In contrast, the Medical Director reported not being invited to any QAA meetings and confirmed non-attendance. The facility's QAA policy requires the committee to include, at a minimum, the Committee Chairperson, Administrator, Director of Nursing, and Medical Director.