Infection Control Committee Lacks Required Maintenance Staff Participation
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. The plan mandates the inclusion of a representative from various departments, including medical staff, administration, laboratory, nursing, pharmacy, physical plant, patient safety, infection control, and the community. However, upon review of the infection control committee meeting attendance records from January to October 2024, it was found that there was no evidence of participation from a physical plant representative, specifically maintenance staff. Interviews conducted with the maintenance director and the nursing home administrator confirmed the absence of maintenance department representation in the infection control committee meetings. The maintenance director acknowledged that he had not attended any meetings and confirmed the lack of attendance from his department upon reviewing the attendance signatures. This deficiency was further corroborated by the nursing home administrator and the director of nursing, who confirmed the absence of required members at the meetings as per the available documentation.
Plan Of Correction
1. No residents were affected by the deficient practice. 2. There are no other residents to protect in a similar situation. 3. The IDT / ABX Stewardship and Infection Control Committee will be educated on the ACT 52 requirement specifically regarding required member participation. 4. Administrator / designee will audit the 4th quarter ABX Stewardship / Infection Control Committee to validate attendance by all required members per the ACT 52 Standard. 5. Date of Compliance 1/30/2025.