Infection Control Meeting Deficiency
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Meetings for four consecutive quarters. The MCARE Act mandates that a health care facility's infection control plan must include a multidisciplinary committee with representatives from various sectors, including medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, patient safety officer, a community member, and a member of the infection control team. Upon reviewing the facility's Infection Control Meeting attendance records for all four quarters of 2024, it was found that a community member was consistently absent from these meetings. This deficiency was confirmed during an interview with the Infection Preventionist, who acknowledged the absence of the community member in the meetings. This oversight indicates a failure to comply with the infection control plan requirements as stipulated by the MCARE Act.
Plan Of Correction
A new community member representative has been identified. An individual meeting with the new Infection Control Committee Meeting community member representative has been coordinated to provide a summary of the last meeting and the next meeting date. The NHA has re-educated the Infection Prevention Coordinator regarding the need to have a community member at the quarterly Infection Control Committee Meeting, and the need to confirm availability and attendance in advance of the meeting date. Audits will be completed monthly by the NHA and/or designee to ensure a meeting invite has been sent to the community member representative. Attendance will be confirmed following each quarterly meeting. Audits will be completed for 2 meetings or until substantial compliance is achieved. Results will be reviewed at the quarterly QAA meeting.