Infection Control Meeting 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 ensure that all required multidisciplinary members were present at the Infection Control Meetings. The absence of a community member was noted for all four quarters of the year, and laboratory personnel were missing for one quarter. This deficiency was identified through a review of the facility's Infection Control Meeting attendance records for the entire year of 2024. During an interview, the Nursing Home Administrator confirmed the absence of the required members at the meetings. The regulation requires a multidisciplinary committee to 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 failure to include these members, particularly a community member and laboratory personnel, indicates non-compliance with the infection control plan requirements as outlined in the MCARE Act.
Plan Of Correction
The 2025 infection control meetings have been established. Communication about scheduled infection control meetings will be sent to all committee members prior to each meeting. Committee members who do not RSVP or participate in the scheduled meeting will be asked to connect with the infection preventionist to review the summary of the meeting. The missing committee member may also view a securely recorded version of the meeting to share their feedback. The infection preventionist will ensure that attendance is documented for all meetings and whether the committee member participated in person, via Zoom, or via recording. The sign-in sheets will be shared with the QAPI committee to verify infection control committee required participation at least quarterly in 2025. Any identified trends by the QAPI or infection control committee will be addressed for performance improvement.