Infection Control Committee Deficiencies
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 the Infection Control Committee meetings included the nine required multidisciplinary members, such as a community member and a patient safety officer, for four consecutive quarters. Additionally, the facility did not hold Infection Control Committee meetings for six months spanning from October 2024 to March 2025. These deficiencies were confirmed through staff interviews and a review of the facility's Infection Control Committee attendance records. During interviews, both the Infection Preventionist RN and the Nursing Home Administrator acknowledged the absence of the required multidisciplinary members at the Infection Control meetings and the failure to conduct these meetings for the specified months. The lack of compliance with the infection control plan as outlined in the MCARE Act indicates a significant oversight in maintaining the health and welfare standards for residents, as mandated by federal and state regulations.
Plan Of Correction
1. Facility will have required attendees for quarterly Infection Control meetings. 2. NHA to educate DON/designee of required Infection Control attendees. 3. DON/designee to educate all required attendees and attendance requirements. 4. DON/designee to audit Infection Control meeting required attendees and notification to resident/resident representative of acquired healthcare associated infections while at the facility monthly x 6 months.