§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.
§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 staff interview and document review, it was determined the facility failed to develop a water management program based on a risk analysis of the facility for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).
Findings include:
On June 4, 2024, the facility provided a policy, titled "Legionella Surveillance and Detection", last revised September 2022. The policy focused on the signs and symptoms of Legionnaires' Disease when a resident develops pneumonia.
On June 4, 2024, the facility was requested to provide their water management program that includes a water flow schematic, a documented risk analysis for areas at risk of contamination with Legionella (gram negative bacteria), and any routine preventative measures being performed that includes water temperature logs, flushing of stagnant water flow systems. The facility in response provided the Center for Disease Control (CDC) toolkit, titled "Developing a Legionella Water Management Program."
During an interview with the Nursing Home Administrator (NHA) on June 6, 2024, at 11:00 AM, the NHA was unable to provide a detailed water management program specific to the facility. The NHA also stated that maintenance staff was preparing a water flow schematic that was provided on June 6, 2024, at approximately 1:00 PM. The water flow schematic failed to show water flow for the facility.
28 Pa. Code 201.18(b)(1)(3) Management
| | Plan of Correction - To be completed: 07/01/2024
Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.
1. A detailed water management program was developed with a schematic of water flow for the facility. 2. The Legionella annual test was completed on 6/14/24. Water temperature logs are completed 2x weekly. Flushing of stagnant water is completed 1x weekly. Facility hot water heater that has a monitoring system that regulates water flow. 3. The facility's Water management program will be reviewed annually by NHA, DON, IFC Nurse, and Maintenance Director. 4. Maintenance Director/Designee will audit water temp logs and flushing of stagnant water weekly x4 and then 2x monthly x1. Results of the audits will be reviewed at the QAPI committee meeting monthly x2 by the Maintenance Director/Designee for any further recommendations. 5. Date of compliance July 1, 2024.
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