Based on interview, record review, and policy review, the provider failed to ensure medical director EE attended and meaningfully participated in the provider's Quality Assurance and Assessment (QAA) meetings at least quarterly. Findings include:1. Interview on 2/19/26 at 11:25 a.m. with administrator A revealed that the QAA committee meets monthly. She texted medical director EE monthly to remind him of when the meetings were, and he usually texted topics he wished the committee to discuss. He sometimes would attend via telephone. He did not have a nurse practitioner or physician's assistant to attend in his absence. She confirmed she was aware that the medical director was required to attend at least quarterly. 2. …
F868 citations in South Dakota
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F868 more often than its own record predicts
2.17 times the share F868 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F868 findings written in South Dakota, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else South Dakota surveyors cite →
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