Failure to Hold Required Quarterly QAA/QAPI Committee Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required by its own Quality Assurance and Performance Improvement (QAPI) Program policy and state regulation. The written QAPI policy dated 8/15/25 stated that the QAA Committee, responsible for both QA and PI activities, would meet on a regular basis at least quarterly to coordinate and evaluate QAPI activities. Review of QAPI sign-in sheets and attendance records showed no documentation that QAA/QAPI meetings were held for the second and third quarters of 2025. During an interview, the Administrator confirmed that the facility did not conduct the required quarterly QAA meetings for those two quarters. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the facility’s failure to hold and document the mandated QAA Committee meetings in accordance with its policy and 28 Pa Code 201.18(e)(1)-(4).
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