Failure to Hold Quarterly QAA Meetings with Medical Director Attendance
Penalty
Summary
The facility failed to ensure that its Medical Director attended all required quarterly Quality Assessment and Assurance (QAA) Committee meetings. Documentation provided by the facility showed that QAA meetings were held on three occasions within the year, but there was a six-month gap between two of the meetings, and only three out of four required quarterly meetings were documented. Additionally, the Medical Director was absent from one of the documented meetings. Administrative staff confirmed that QAA meetings should be held quarterly and that the Medical Director is required to attend, verifying both the lack of quarterly meetings and the Medical Director's absence at some meetings. The facility's policy states that the QAA committee, which includes the Medical Director among other key staff, is responsible for overseeing and implementing the quality assurance and performance improvement program. The committee is required to meet at least quarterly to fulfill its responsibilities, which include analyzing performance data, identifying and resolving care quality problems, and communicating findings to the administrator and governing body. The failure to hold quarterly meetings and ensure the Medical Director's attendance represents a deviation from both regulatory requirements and the facility's own policy.