Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the required members in attendance. Review of the QA&A committee attendance rosters showed that the Medical Director was only present at two of the documented meetings, and there was limited information available regarding the QA&A process prior to the current administrator's employment. The current administrative staff member reported not having received training related to the QA&A process and confirmed that only one meeting involving the Medical Director had occurred since her employment began. The facility's own policy required the QA&A team to meet monthly and quarterly, with membership including the DON, a physician, and at least three facility staff members, but these requirements were not consistently met.