Infection Control Committee Lacks Required Community Member
Penalty
Summary
The facility failed to meet the regulatory requirement of having all nine multidisciplinary members present at the Infection Control Committee Meetings for all four quarters of 2024. According to the Medical Care Availability and Reduction of Error (MCARE) Act, the infection control plan must include a multidisciplinary committee with representatives from various departments, including a community member. However, the facility did not have a community member attend these meetings, as confirmed by the Nursing Home Administrator (NHA). The deficiency was identified through a review of the facility's Infection Control Committee Meeting attendance records and staff interviews. The Infection Preventionist confirmed that attendees sign in on the Quality Assurance meeting form, but the NHA admitted that a community member was not present at any of the meetings throughout the year. This oversight indicates a failure to comply with the state regulations requiring a comprehensive multidisciplinary approach to infection control planning.
Plan Of Correction
A member of the community will participate in quarterly infection control meetings. Signature sheet was revised to show this participation. Community member participation will be audited monthly x 3 months. Audit results will be reviewed through the monthly QAPI process.