QAPI Committee Did Not Receive Required Infection Control Report
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to receive a report from the infection preventionist regarding the infection control program for one of the three quarters reviewed. Specifically, during the April QAPI meeting, no data or report on the infection control program was presented for committee review, as confirmed by the meeting minutes. The sign-in sheet for the April meeting showed that the DON, who was also serving as the infection preventionist, was present. During an interview, the administrator stated he was unaware that the infection preventionist had not provided the required data or report and confirmed his own attendance at the meeting. He also noted recent staff turnover, including the resignation of the social service designee and the interim status of the DON, and indicated he had only recently obtained his administrator license. No policy was provided regarding the requirement for the infection preventionist to present infection control data at QAPI meetings.