Failure to Include Required Disciplines in Infection Control Committee
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements outlined in the Act 52 Infection Control Plan. Specifically, the facility did not include representatives from pharmacy or laboratory personnel in its infection control committee meetings, as required by regulation. Documentation provided by the facility, titled "QAPI (Quality Assurance and Performance Improvement) Attendance," was reviewed for several meeting dates, but there was no evidence or signatures indicating that pharmacy or lab staff attended any of these meetings. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that infection control meetings were held during QAPI meetings on a quarterly basis or more frequently if needed. However, attendance records for these meetings did not show participation from pharmacy or laboratory personnel, which is a required component of the multidisciplinary infection control committee. No information about specific residents or their medical conditions was included in the report.
Plan Of Correction
1. Facility is unable to retroactively correct deficiency for past Act 52 meetings. 2. An employee of the Pharmacy and a Representative from the Laboratory have been invited to the next QA/Act 52 meeting. 3. All attempts will be made to ensure all appropriate members are present and will facilitate via phone conference if necessary. The Administrator and DON will be educated on which members of the multidisciplinary committee need to be present for QA/Act 52 meetings. 4. Monthly sign-in sheets for QA/Act 52 will be reviewed to ensure all appropriate members of QA/Act 52 meeting was present monthly and results will be forwarded to QA meeting to ensure ongoing compliance.