Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
No actual harm occurred, but a finding has the potential for more than minimal harm if uncorrected.
CMS uses a scope/severity grid (A through L). Letters A-F indicate no actual harm, G-I indicate actual harm, and J-L indicate immediate jeopardy. Scope (isolated, pattern, widespread) is encoded in the same letter.
Status: Deficient, Provider has no plan of correction.