CMS Manual System - Louisiana Department of Health and Hospitals

The assigned surveyor should interview staff in various departments to determine if they
know how to bring an issue to the attention of the QAA committee.
If, during the course of the survey, the survey team identifies noncompliance at a
particular requirement, the assigned surveyor should interview the designated person
responsible for the QAA committee to determine whether the committee knew of or
should have known of the issues related to the noncompliance. The assigned surveyor
should determine if the committee had considered the quality deficiency and if it was
determined that an action plan was needed. If so, the surveyor determines whether the
committee developed and implemented any action plans to address these concerns. The
survey team should verify that the action plans that are described are actually
implemented, and that staff are providing care and services according to the directives of
these action plans.
DETERMINATION OF COMPLIANCE (Task 6, Appendix P)
NOTE: Although the literature of QAA and QI provides various definitions of the
facility‘s achievement of quality, surveyors will need to determine the facility‘s
compliance based on the language of this regulation.
Synopsis of Regulation (F520)
This requirement has two aspects: the facility must have a committee composed of
certain key members that meets at least quarterly (or more often, as necessary); and the
committee functions to develop and implement appropriate plans of actions to correct
identified quality deficiencies.
Criteria for Compliance
The facility is in compliance if:
It has a functioning QAA committee, consisting of the director of nursing, a
physician, and at least three other staff members, that meets at least quarterly; and
The committee:
If not, cite F520.
o Identifies quality deficiencies; and
o Develops and implements appropriate plans of actions.
Noncompliance for F520