Infection Control Committee 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 Committee Meetings for all four quarters of 2024. The required members include laboratory personnel, physical plant personnel, and pharmacy staff, among others. The absence of these key personnel was noted in the attendance records for each quarter, indicating a consistent failure to comply with the regulation. In Quarter 1, laboratory personnel were not present at the meeting. In Quarter 2, the absence extended to laboratory personnel, physical plant personnel, and pharmacy staff. Quarters 3 and 4 again saw the absence of laboratory personnel. This deficiency was confirmed during an interview with the Infection Preventionist, who acknowledged the facility's failure to ensure the presence of all required multidisciplinary members at the meetings.
Plan Of Correction
All 9 of the required Multidisciplinary team members will be present at the quarterly Infection Control/QAPI meeting. All members will be notified of when each quarterly Infection Control/QAPI meeting will be held and all signatures of those attending will be obtained. Members who attend via phone or video will be documented/signed as such for their attendance. Education will be provided to all Multidisciplinary team members by the RNAC or designee on their requirement to attend the Infection Control/QAPI meeting each quarter and to ensure they are signing the attendance log. Attendance/ signatures will be monitored at each quarterly Infection Control/QAPI meeting by the RNAC or designee.