Non-Compliance with Infection Control Committee Requirements
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. This plan mandates that a health care facility develop and implement an internal infection control plan aimed at improving the health and safety of residents and health care workers. The plan should include a multidisciplinary committee with representatives from various departments, such as medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, members from the infection control team, and community representatives. However, the facility was unable to provide evidence of the infection control committee meetings and attendance records since the last standard survey. During interviews with the Nursing Home Administrator and the Director of Nursing, who also serves as the facility's infection preventionist, the surveyor requested documentation of the infection control committee meetings. Despite repeated requests, the facility did not provide the necessary evidence, indicating a failure to adhere to the infection control plan's requirements. This deficiency highlights the facility's non-compliance with the established standards for infection control, as outlined in the Act 52 Infection Control Plan.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No individual resident was identified as impacted. 2. A multidisciplinary committee is being assembled that meets the requirements of Act 52, and a meeting will be scheduled to be held at least quarterly. 3. The Regional Director of Operations will educate the current NHA on the need to assemble a multidisciplinary committee that meets the requirements of Act 52, and that a meeting is to be scheduled and held on a quarterly basis. 4. The Regional Director of Operations will audit to ensure that a multidisciplinary committee that meets the requirements of Act 52 is in place, and that a meeting was scheduled and held on a quarterly basis. Audit findings will be reviewed at the QAPI meeting.