F0868

D

Failure of Medical Director to Attend QAA Meetings at Least Quarterly

Milbank, South Dakota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the medical director attended and meaningfully participated in Quality Assessment and Assurance (QAA) committee meetings at least quarterly as required. During an interview, the administrator stated that the QAA committee meets monthly and that she texted the medical director each month to remind him of the meetings; he typically responded by texting topics for the committee to discuss and only sometimes attended by telephone. The administrator acknowledged she was aware that the medical director was required to attend at least quarterly and that he did not have a NP or PA to attend in his absence. Review of the QAA committee binder showed the medical director attended via telephone at the most recent meeting in late January 2026 and attended in person in mid-August 2025, but for all other months in 2025 he either did not attend or only sent texted topics instead of participating in the meetings. Review of the facility’s QAPI policy from July 2025 confirmed that the medical director was designated as a QAA committee member and that the committee was required to meet at least quarterly.