QAA Committee Lacked Required Members During Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee included all required members during scheduled meetings, as evidenced by missing signatures from key committee members on multiple occasions. Record review of QAA Committee sign-in sheets revealed that on one date, the Infection Preventionist, Director of Nursing, and Medical Director did not sign in, and on another date, the Infection Preventionist's signature was missing. Staff interviews confirmed that the QAA committee met at least quarterly, but the Administrator could not explain the absence of required members at certain meetings, noting that there was no Infection Preventionist employed at the time of one meeting. Facility policy specifies that the QAA committee must include the Administrator, DNS, Medical Director, Infection Control Nurse, and at least three other members.