The following are some key QA facts to keep in mind:
■ Incident reports containing factual information are not privileged, and investigative reports prepared in the context of required FRI reports cannot be shielded from surveyors.
■ When preparing incident reports, keep all opinion, analysis, and action items out.
■ Final FRI reports should strictly comply with, and include, only information required by regulation.
■ Monthly fall logs and other analytical documents should be prepared at the direction of the QA committee as stated in its minutes and provided to the committee or a member of the committee in his or her official capacity for review, analysis, and discussion, to ensure that they can be considered QA documents.

Store these documents in QA record files.
■ Maintain QA minutes to prove that substantive discussion has occurred and keep all opinion and analysis in the QA committee minutes, as opposed to other documents.
■ Store QA committee records, minutes, and analysis in a separate, secure, labeled location.
■ The QA committee must direct that monthly fall logs or other similar compilations are prepared, maintained, and reported to the committee. Fall logs for individual residents maintained in individual resident files are likely not privileged under federal law because they constitute factual data in the medical record.
■ If surveyors ask to review QA files, diplomatically assess the rationale for the request. If the purpose of the review is to assess the committee’s composition and identification of issues requiring action, the review is appropriate but should be limited to showing agendas, meeting attendance records, and committee members. However, do not release copies of any record the facility has identified as a QA record.

An onsite review is all that is needed to assess compliance with QA committee requirements.
■ There may be situations when QA minutes or deliberations need to be shared with surveyors to address a particular survey issue. If so, do not provide copies, and if possible, involve legal counsel.
■ Clearly label documents intended to be privileged as such, pursuant to 42 CFR §483.75(o).