|§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 review of the facility's infection control data collection and staff interview, it was determined that the facility failed to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff.
Review of the facility's infection control plan revealed the facility failed to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections within the facility from October 1, 2018 through January 30, 2019.
Interview with the Director of Nursing and Employee 4, registered nurse, confirmed these findings on February 13, 2019, at 11:30 AM.
42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control
Previously cited 01/09/18
28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/14/18 and 01/09/18
| ||Plan of Correction - To be completed: 04/01/2019|
No residents were harmed based on this deficient practice. Infection control plan reviewed.Infection control plan reviewed with Infection Control Nurse and log line listing implemented immediately to be tracked beginning 2/1/2019.
Any resident that has documented s/s of infection has the potential to be affected by this deficient practice. In order to prevent this from occurring, log line listing will be used for tracking and trending infections. Infection Control Nurse educated on facility's infection control plan including but not limited to, log line listing, tracking/trending, and reporting.
A weekly audit will be conducted for all residents showing s/s of infection that meets the criteria of a reportable disease. This weekly audit will be conducted for a period of 12 weeks.
Results of the audit will be forwarded to the quality assurance committee for recommendations and discussion. The director of nursing, or designee, will oversee this process.