Failure to Hold Required QAA Meeting with All Committee Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of four quarterly meetings in 2025. According to the facility's Quality Assurance/Performance Improvement policy, meetings are to be held at least quarterly to identify non-compliant service areas or those with potential for improvement. Review of sign-in sheets and attendance records for the third quarter of 2025 showed that the Infection Preventionist, Director of Nursing, and Medical Director were not present. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required QAA meeting did not occur with all mandated members present as stipulated by facility policy and state regulations. No information regarding specific residents, their medical history, or condition at the time of the deficiency was provided in the report.