|§483.80 Infection Control|
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of two nursing units (Second floor nursing unit, Resident 324).
Observation of incontinence care provided to Resident 324 on April 9, 2019, at 9:54 AM revealed that Employees 2 and 3, nurse aides, removed the urine soaked brief, and placed a lift pad under the resident. Employee 2 used the lift controls with her contaminated gloved hands and opened the resident's dresser with the same gloves. At 10:08 AM, Employee 2 put the lift at the end of the hallway without cleaning it after she touched it with her contaminated gloves.
The findings were discussed during an interview with the Nursing Home Administrator on April 11, 2019 at 11:00 AM.
28 Pa. Code 201.18(b)(1) Management
Previously cited 5/11/18
28 Pa. Code 211.10(d) Resident care policies
Previously cited 6/20/18 and 5/11/18
| ||Plan of Correction - To be completed: 05/28/2019|
Preparation and/or execution of this provider's plan of correction does not constitute admission or agreement of the truth of facts alleged, or conclusions set forth in the Statement of Deficiencies, as perceived by representatives of the Department of Health relative to the annual survey ending April 12, 2019. This provider's plan of correction is prepared because it conveys the sincere message of the governing body as follows:
All representative entities of the Susquehanna Health Skilled Nursing & Rehabilitation Center have been and will be committed to providing the highest quality of care and services to the elderly, in accordance with or exceeding all applicable local, state and federal laws/mandates regarding the operation of the long term care facility in the Commonwealth of Pennsylvania.
The following plan of correction comprises our allegations of compliance with regulatory requirements contained in 483, Subpart B Requirements for Long Term Care and Title 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
1. Hoyer lift was cleaned.
2. Facility lift audit completed for lift cleanliness.
3. Staff education on lift cleaning process and proper infection control practices during resident care.
4. Weekly observations of lift cleanliness after use for 3 months with results report to QAPI by Infection Preventionist or designee.