Infection Control Committee Lacks Required Members
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's Infection Control Committee did not include the required multidisciplinary members, such as laboratory personnel, during meetings for two of the four quarters in 2024. This deficiency was identified through a review of the facility's Infection Control Committee Attendance Log, which showed the absence of laboratory personnel in Quarters Three and Four of 2024. Additionally, during an interview, an administrative assistant confirmed the absence of both laboratory personnel and pharmacy staff in the attendance log for Quarter Four of 2023, further highlighting the facility's non-compliance with the infection control plan requirements.
Plan Of Correction
The laboratory member of the QAPI committee has been re-educated on attending the QAPI meetings at least quarterly. Email invitations are provided and a zoom option offered. The administrator will note if attendance is by zoom. Laboratory personnel did attend the QAPI meeting on January 16, 2025. On 1/28, all personnel sign in for the QAPI meetings including laboratory personnel. This sign in sheet serves to monitor attendance for all required personnel.