Infection Control Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure the presence of three required multidisciplinary members at the Infection Control Committee meetings, as mandated by the Medical Care Availability and Reduction of Error (Mcare) Act. Specifically, laboratory personnel, physical plant personnel, and a community member were absent from these meetings. The review of the facility's attendance records for the Quality Assurance Performance Improvement (QAPI) and Infection Control meetings revealed that during the second, third, and fourth quarters of 2024, these members did not attend any of the monthly meetings. During an interview, the Nursing Home Administrator confirmed that the facility holds these meetings monthly and attempts to have all required attendees present at least once per quarter. However, she acknowledged that the required members failed to attend as expected. She also mentioned that the absence of Physical Plant Personnel was due to instructions from the corporate office, which indicated that their attendance was not necessary.
Plan Of Correction
1. The facility was evaluated on the review of the facilities' Infection Control Committee attendance records to ensure this standard of operation set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents were being followed by all attendees present on a monthly basis. The Infection Control Committee meeting includes Medical Staff, Nursing Staff, Administration, laboratory personnel, physical plant personnel, Safety Officer, and a community member. Attendance will be mandated accordingly and deficiency corrected by March 14, 2025. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. The Infection Control Committee will continue to meet monthly to ensure an Infection Control plan as stated is developed and implemented that includes a multidisciplinary committee, including representatives from each of the specific health care facility to include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, community member, laboratory personnel, pharmacy staff, and infection control team members. 3. All Infection Control Committee members will be re-educated on monthly mandated attendance to ensure three of nine required multidisciplinary members are present to meet compliance standards and regulation by March 14, 2025. The NHA will invite the committee a month before the next meeting and send reminders out a week prior to the scheduled meeting date to ensure 100% participation is achieved. 4. The NHA will conduct monthly audits for 3 months to ensure attendance of members. If 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the NHA and discussed at the monthly QAPI meeting to determine the need for further audits and/or action plans.