Infection Control Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that its Infection Control Committee meetings included all required multidisciplinary members for four consecutive quarters. 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 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. However, the facility's attendance records revealed that key members were consistently absent from these meetings. In the first quarter, the medical director was not present at the Infection Control Committee meeting. In the second quarter, the pharmacy representative was absent. The third quarter saw the absence of the medical director, infection preventionist, lab, and pharmacy representatives. Finally, in the fourth quarter, the pharmacy representative was again not in attendance. These absences indicate a failure to comply with the required composition of the infection control committee as mandated by the MCARE Act.
Plan Of Correction
1. Infection control data for quarters 1 and 3 2024 was reviewed by the medical director. Data from quarters 2, 3 and 4 2024 was reviewed by the consultant pharmacist. Data from quarter 3 2024 was reviewed by the infection preventionist and lab personnel. 2. An audit was done of 2024 infection control committee logs to ensure all other required persons were in attendance. 3. Director of nursing or designee will in-service all persons required for infection control committee meetings on meeting scheduled and required attendance. 4. Director of nursing or designee will audit attendance sheets quarterly to ensure all required persons are in attendance. Audit findings will be shared with QAPI committee.