Failure to Hold Required Quarterly QAA Committee Meeting
Penalty
Summary
The deficiency involves the facility’s failure to conduct required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated committee members. Federal regulations require that the QAA committee include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including an individual in a leadership role such as the administrator, and the infection preventionist (IP), and that this committee meet at least quarterly to coordinate and evaluate activities under the QAPI program. The facility’s own “Quality Assurance and Performance Improvement (QAPI)” policy, dated 1/5/26, states that the QAPI program is an ongoing comprehensive program addressing all systems of care and that meetings are to occur at least quarterly, monthly, or more often if needed. Surveyors reviewed QAPI sign-in sheets and attendance records for Quarter Four of 2025 and did not find evidence that a QAA meeting was held during that quarter as required. During an interview on 4/10/26 at 10:40 a.m., the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members for one of the four quarterly meetings, specifically Quarter Four of 2025. No resident-specific information, medical histories, or clinical conditions were described in relation to this deficiency.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026. A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation.
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