Infection Control Meeting Deficiency
Penalty
Summary
The facility was found to be non-compliant with the requirements set forth by the Medical Care Availability and Reduction of Error (MCARE) Act, specifically regarding the composition of its Infection Control Meetings. The regulation mandates that a multidisciplinary committee, including a community member, must be present at these meetings. However, during the review of the facility's Infection Control Meeting attendance records for the fourth quarter, it was discovered that a community member was not present, thus failing to meet the required composition of the committee. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of a community member in the Infection Control Meetings for one of the four quarters. The absence of this required member indicates a lapse in adhering to the infection control plan as stipulated by the MCARE Act, which necessitates the inclusion of various representatives to ensure comprehensive infection control oversight.
Plan Of Correction
All required attendees failed to attend the Infection Control Committee meetings. Facility is unable to retroactively correct this citation. From the date of exit (1/16/2025) forward the facility will maintain Infection Control Committee attendance requirements according to the regulation. To prevent this from happening again the RVPO/designee educated the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained. To monitor and maintain ongoing compliance the RVPO/designee will audit Quarterly x3 to ensure the facility's QAPI meeting is occurring quarterly per the regulation and that attendance records are maintained.