Infection Control Committee Attendance 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 provide evidence that the nine required multidisciplinary members were present at the Infection Control Committee meetings for six consecutive months from August 2024 to January 2025. The required members include representatives from medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, a community member, and a member of the infection control team. The attendance logs for these months showed only the Administrator, Medical Director, and a Community Member with photocopied signatures, indicating a lack of proper documentation and participation. Additionally, the facility was unable to produce any signature sheets for the Infection Control Committee meetings held from February 2024 to July 2024. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to provide evidence of the required multidisciplinary attendance at the meetings. This deficiency highlights a significant lapse in the facility's infection control practices, as it did not adhere to the mandated standards for committee composition and documentation over an extended period.
Plan Of Correction
Data for 6/6 months are not able to be rectified by facility for previous data. IP Employee E20 will be re-educated on Infection Control and Prevention responsibilities by the DON of at least quarterly infection control meetings per regulation with 9 required in person signatures. Team members of the infection control committee will be educated on attendance requirements by the DON/Designee. The Infection Preventionist will conduct a quarterly infection control meeting in the month of April for the first quarter. The DON/Designee will audit quarterly meetings x 2 to ensure meeting occur per regulation. The results of the education and audits will be shared at the monthly QAPI meeting for review and approval.