Improper Constitution of Quality Assurance Committee
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee was properly constituted, as required by regulations. Specifically, the Director of Nursing was also serving as the Infection Preventionist, which is not permissible. The facility's Quality Assurance and Performance Improvement Plan outlined that the committee should include the Administrator, Medical Director, Director of Nursing, and Infection Preventionist, among others. However, due to staffing issues, the Director of Nursing was fulfilling multiple roles, including that of the Infection Preventionist and Nurse Educator. This dual role was not recognized by the Administrator, who was unaware that the Infection Preventionist should be a separate position. The facility's policy and procedure for Infection Prevention and Control, last revised in 2024, stated that the Infection Prevention and Control Committee should oversee the implementation of infection control policies and practices. During interviews, it was revealed that the facility held monthly meetings, but the responsibility for signing in was left to the staff. The Administrator admitted to being unaware of the requirement for the Infection Preventionist to be a distinct role, which contributed to the deficiency. This oversight had the potential to affect all residents of the facility, as the committee's role is crucial in coordinating and evaluating performance improvement projects.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The QAPI policy was reviewed with no changes. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: Audits of QAPI attendance will be completed to ensure the IP is present. This will be completed x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Administrator by 3/31/25.