Failure to Hold Required Quarterly QA&A Committee Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QA&A) Committee met at least quarterly with required members, including facility administration and the medical director, as outlined in its QAPI plan dated 1/2/26. The QAPI plan specified that the QA&A Committee was responsible for meeting at a minimum on a quarterly basis, coordinating and evaluating QAPI activities, developing and implementing plans of action to correct identified quality deficiencies, and regularly reviewing and analyzing collected data, including data from drug regimen reviews. Record review showed that the most recent QA meeting sign-in sheet documented a QA meeting in July 2025, with no subsequent meetings held. During an interview on 2/10/26 at 11:15 AM, the Corporate President of Operations stated that the facility had not conducted a QA meeting since July 2025 and that there were no records available to show when meetings were held prior to that date. She reported that when the Administrator in Training started in July 2025, the administrator was informed that QA meetings were to be held monthly per facility suggestion and quarterly per regulatory requirements, but she was unaware that these meetings were not being conducted. The facility’s daily census report dated 1/26/26 documented that 53 residents resided in the facility at the time of the deficiency.
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