Failure to Ensure DON Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), a required member, attended the quarterly Quality Assessment and Assurance (QAA) committee meetings. According to the facility's QAPI Plan and supporting documents, the QAA meeting is to be conducted every three months and must include key personnel, including the DON. However, review of the QA meeting sign-in sheet for a meeting dated July 15, 2025, showed the DON's signature, but upon interview, the DON confirmed she was on vacation in Hawaii on that date and could not have attended the meeting. The DON further stated that she was given the sign-in sheet to sign as part of the QA meeting team, but the date and quarter reviewed were handwritten on the sheet after she signed it, and she had not attended any official QA meeting since her start date of May 27, 2025. The Administrator also confirmed that the DON was on vacation on the date of the alleged meeting and could not have been present. The facility's records indicate that there are currently 70 residents residing in the facility. The deficiency centers on the lack of required participation by the DON in the QAA committee meetings, as mandated by facility policy and federal regulations.