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3.18 – Quarterly Infection Control/Medical Review Committee

Purpose

The purpose of the Infection Control/Medical Review Committee is to provide oversight and direction on the coordination of medical services and facility infection control.  The committee consists of nursing staff, administration, Medical Director, contract laboratory representative, pharmacy representative, and radiology representatives, as needed. This committee meets quarterly with minutes and signature sheets maintained in the designated Nursing office notebook.

Procedure

Open Door is responsible to ensure that all individuals receive general health care services. General health care services include assessment and treatment of acute complaints or situations; teaching relevant heath care principles to staff and individuals; and periodic surveillance of the health status of the clients.  As a result of clinical assessment, referrals are made for specialized assessments and tests. The facility health care staff are responsible to ensure all referrals, assessments, and tests are completed timely and per orders.  The findings must be incorporated into the medical care plan and/or the IPP. This includes arranging routine or episodic laboratory, and radiology services for the individuals per physician orders and team recommendations. 

Preventive health care services include screening procedures designed to identify health concerns and initiate treatment as early as possible. The facility has a health prevention program in place that requires screenings that the facility will perform periodically are relevant to all clients and those screenings associated with a particular gender or age or vulnerability.     

Additionally, the Nursing staff actively participate in surveillance and reporting of communicable diseases per CDC guidelines and applicable State laws.  The nursing staff teach and promote infection control techniques such as hand washing by clients and staff and should be making periodic observations to ensure that such good infection control techniques are consistently utilized.

Committee Review

Each quarter, the following areas will be reviewed during the Medical team review meeting to ensure that all follow-up has been completed according to the procedures above:

  • Infection control reporting logs and analysis
  • Pharmacy recommendations
  • Laboratory reports and outstanding needs
  • Radiology reports and outstanding needs
  • Physician reports and outstanding needs
  • Team review and input

The nursing chairperson or designee is responsible to compile and prepare these reports for review during the meeting.  The committee ensures that all follow-up recommendations are completed and makes any further recommendations for team response. 

This committee also is responsible to review all infection control reports and provide additional recommendations for training needs, facility response, equipment or supply needs.

The nursing chairperson is responsible to ensure completion of meeting minutes, signature sheets, and recommendation completion and response within 7 business days of each quarterly meeting.  These records will be maintained in the designated notebook in the nursing office.

Last Revised: 8/24/21

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