§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 §483.71 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.
§483.80(e) Linens.
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.
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Observations:
Based on a review of select facility policies and procedures, Centers for Disease Control standards, observation, review of personnel payroll records, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to resident personal laundry processing and COVID-19 work exclusions (Employee 3).Findings include:Observation of the facility's resident personal laundry processing procedure on April 18, 2025, at 9:32 AM with Employee 4 (environmental services manager) and Employee 5 (operations manager) revealed that staff gather resident soiled personal laundry in a mesh bag in the resident's room. Staff transfer the soiled resident laundry from the resident room to a large, open, cart in the nursing unit's soiled utility room in the mesh bag.The mesh bag would not provide leak-resistant protection for staff to prevent the potential contamination of their clothing from resident bodily substances during transport.Observation of nursing unit's soiled utility room with Employees 4 and 5 on April 18, 2025, at 9:35 AM revealed a large, open, bin where mesh bags of soiled resident laundry are held. There was no lid to the bin. Interview with Employees 4 and 5 on the date and time of the observation revealed that nursing staff are instructed to rinse heavily soiled garments in the soiled utility hopper before placing the items in the open cart. The interview confirmed that there were no isolation gowns in the soiled utility room to protect staff clothing from splashes should staff rinse the potentially infectious clothing in the soiled utility room. The action of rinsing any contaminated laundry in the soiled utility room would result in some agitation that could potentially contaminate the air, surfaces, and persons in the soiled utility room (who would not have eye protection or isolation gowns for protection). The interview indicated that staff from the facility's laundry department don gloves to collect the mesh bags from the large open bin to transfer them to their large, lidded, bins for transport to the facility's main soiled utility room on another floor. The interview confirmed that laundry staff do not don an isolation gown before transferring the mesh bags; therefore, there is the potential for uncontained infectious material from the soiled laundry to leak through the mesh bags potentially contaminating the staff's clothing during the transferring of the mesh bags from bin to bin. The action of transferring the mesh bags in the soiled utility room would result in some agitation that could potentially contaminate the air, surfaces, and persons in the soiled utility room (who would not have eye protection or isolation gowns for protection).The surveyor reviewed the above concerns regarding the facility's resident personal laundry processing with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.The facility policy entitled, "COVID-19 Testing and Exposure Management," last reviewed on September 6, 2024, revealed that if COVID-19 is confirmed, staff should follow Centers for Disease Control (CDC) guidance "Interim Guidance for Managing Healthcare Personnel with SARSCoV-2 (COVID-19) Infection or Exposure to SARS-CoV-2." Conventional return-to-work criteria is that, regardless of vaccination status, staff would return in 10 days or in seven days with a negative test, if asymptomatic or with mild to moderate illness (with improving symptoms).Centers for Disease Control criteria for staff to return to work following COVID-19 infection (https://www.cdc.gov/covid/hcp/infection-control/guidance-risk-assesment-hcp.html?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html) revealed that health care personnel (HCP) with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:At least seven days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), andAt least 24 hours have passed since last fever without the use of fever-reducing medications, andSymptoms (e.g., cough, shortness of breath) have improved.(If using an antigen test (can give results in as little as 15 minutes, do not require laboratory testing for the results), HCP should have a negative test obtained on day 5 and again 48 hours later)CDC permits earlier return to work parameters in situations where contingency or crisis staffing criteria are met (https://www.cdc.gov/covid/hcp/infection-control/mitigating-staff-shortages.html). CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency strategies followed by crisis strategies are provided to augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing conventional strategies followed by contingency strategies followed by crisis strategies). The guidance is for healthcare facilities that are expecting or experiencing staffing shortages due to COVID-19. For example, if, despite efforts to mitigate, HCP staffing shortages occur, facilities might determine that, to ensure the availability of healthcare, certain HCP with suspected or confirmed COVID-19 infection should return to work before the full conventional Return to Work Criteria have been met. Healthcare facilities (in collaboration with risk management) would inform residents and HCP when the facility was utilizing these strategies, specify the changes in practice that should be expected, and describe the actions that would be taken to protect residents and HCP from exposure to COVID-19 if HCP with suspected or confirmed COVID-19 infection are requested to work to fulfill staffing needs. These would include:Understand the local epidemiology of COVID-19-related indicators (e.g., community transmission levels).Communicate with local healthcare coalitions and federal, state, and local public health partners to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed.Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities.Cancel all non-essential procedures and visits. Shift HCP who work in these areas to support other patient care activities in the facility. Attempt to address social factors that might prevent HCP from reporting to work, such as need for transportation or housing that allows for physical distancing.Identify additional HCP to work in the facility.As appropriate, request that HCP postpone elective time off from work.Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection.Interview with Employee 3 (nurse aide) on April 16, 2025, at 2:30 PM revealed that she tested positive for COVID-19 twice in the past year. Employee 3 stated that she returned to work approximately five days after her positive test on each occasion but that she had no COVID-19 testing after her initial positive result. Employee 3 stated that she decided to test for COVID-19 because she had symptoms of the common cold each time she tested positive.Review of the facility's submissions to the Department of Health Event Reporting System (ERS, online system established for facilities to comply with required notification to the Department of the facility's reportable events) revealed that Employee 3 tested positive for COVD-19 on November 4, 2024, (ERS report 1047840, day zero).Review of Employee 3's timecard revealed that she worked November 9, 10, 11, 13, and 14 2024, (days 5 through 10) after her positive result.Review of the facility's ERS submissions to the Department revealed that Employee 3 tested positive for COVID-19 on January 2, 2025, (ERS report 1060917).Review of Employee 3's timecard revealed that she worked January 8, 9, and 10, 2025c, (days 6, 7, and 8) after her positive result.The surveyor requested any evidence of COVID-19 testing for Employee 3 dated November 2024, through January 2025, during interviews with the Nursing Home Administrator and the Director of Nursing on April 16, 2025, at 1:00 PM and April 17, 2025, at 2:00 PM; however, the facility did not provide any results during the onsite survey.Interview with the Nursing Home Administrator and the Director of Nursing on April 17, 2025, at 2:00 PM confirmed that the facility had no evidence of additional cases of COVID-19 (besides Employee 3 to support staffing shortages due to COVID-19), had not progressed through any measures between conventional nurse staffing to contingent nurse staffing, nor had any communications with local healthcare coalitions and federal, state, and local public health partners to identify additional HCP that were needed in a contingency staffing situation. The facility had no evidence of measures implemented as an effort to mitigate staffing shortages before implementing CDC's contingency staffing allowances for staff's return to work.The facility permitted Employee 3 to return to work after COVID-19 infection on November 9, 2024 (day 5) and January 8, 2025 (day 6) without any negative COVID-19 testing results, which was outside CDC's conventional strategy parameters.483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 5/10/2428 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 05/22/2025
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. No individual residents were identified as impacted. At the time of the finding environmental staff was verbally reminded about the importance of keeping laundry in sealed bags and the use of PPE during laundry processing.
2. The Director of Nursing and/or designee will educate all environmental service staff and nursing assistants on the need to place resident personal laundry that is in a mesh bag in a plastic bag before removing from the residents' room and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing.
3. The Administrator and/or designee will educate the Director of Nursing and Human Resources on the updates to the facility policy COVID-19 Testing and Exposure Management. Specifically, but not limited to the need to consider the continuum of options for addressing staffing shortages, and that contingency strategies followed by crisis strategies are provided to augment conventional strategies and are meant to be considered and implemented sequentially, as per the CDC, "when staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use capacity strategies to plan and prepare for mitigating this problem." Director of Nursing will also be educated on the need to also consider the PA DOH staffing Ratios and Hours Per Patient Day (HPPD) requirements while balancing strategies to mitigate staffing shortages, safe staffing to meet resident needs and providing evidence of measures considered.
4. The Director of Nursing and/or designee will conduct 5 visual audits per week for 2 months to ensure the environmental service staff and/or nursing assistants place resident personal laundry that is in a mesh bag in a plastic bag for transport and storage and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing. The NHA and/or designee will conduct an audit on the return to work for any employee who is off due to COVID -19 and what was considered to support a return to work outside of the conventional strategies to mitigate staffing shortages. The audit will be completed for 2 months or until substantial compliance is achieved. Audit findings will be reviewed at the QAPI meeting.
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