Infection Control Committee Deficiency
Penalty
Summary
The facility failed to ensure compliance with Pennsylvania state law regarding the operation of a multi-disciplinary infection control committee. According to the Act 52 Infection Control Plan, the facility is required to have a multi-disciplinary committee that meets at least quarterly, including representatives from various departments such as medical staff, nursing, laboratory personnel, and a community member. However, as of January 30, 2025, the facility could not provide documented evidence that the committee included the required laboratory personnel or a community member in its meetings. An interview with the Infection Preventionist confirmed the absence of documented evidence showing the participation of laboratory personnel or a community member in the committee meetings, either in person or via phone. This deficiency indicates a failure to adhere to the infection control plan's requirements, potentially impacting the health and safety of residents and healthcare workers by not having a fully representative committee to address infection control issues.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot go back and correct previously held infection control meetings. There were no other issues at the time of the survey. To prevent a future occurrence, the Regional Director of Clinical Services educated the Infection Control Nurse and Director of Nursing on Act 52. To monitor and maintain ongoing compliance, the facility will have a community member present at infection control meetings quarterly. A lab member will attend a quarterly meeting. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.