|§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 upon review of facility policy and procedures, observation, and interview, it was determined that the facility failed to maintain appropriate infection prevention and control procedures to prevent spread of Covid 19 at the facility.
Review of facility policy and procedure titled Coronavirus and Covid-19 Vaccine Policy, revised 3/11/2022, revealed "Visitors will be subject to all applicable screening and restriction criteria as per the most current CDC, Federal, State and/or Local guidance; Educate and communicate with staff on Covid-19 along with Infection Prevention practices such as: handwashing, isolation practices/protocols; Proper PPE [personal protective equipment] and usage."
Further review of this policy revealed "The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. Facilities must permit residents to leave the facility as they choose. Should a resident choose to leave, the facility should remind the resident and any individual accompanying the resident to follow all recommended infection practices including wearing a face covering or mask, physical distancing, and hand hygiene and to encourage those around them to do the same."
Observation on the first day of the survey, June 26, 2022, revealed signs throughout the facility indicating the facility was in "yellow" status.
Interview with Employees E4 and E5 on June 26, 2022, at 9:30 a.m. revealed surgical masks and no additional face coverings, i.e., goggles or face shields were appropriate for the level of infection control present in the facility.
Interview with the Nursing Home Administrator on June 26, 2022, at 11:00 a.m. confirmed that surgical masks were appropriate and face shields and goggles were not required.
Observation on June 26, 2022, at 2:30 p.m. of the front porch area of the facility revealed approximately seven residents sitting in the front porch area not wearing any face masks.
On the second day of the survey, June 27, 2022, State surveyors were informed that N95 masks and face shields/goggles were required throughout the facility due to the facility's yellow status.
Observation of group meeting held on June 27, 2022, at 11:00 a.m. revealed seven residents in attendance at the meeting not wearing face masks.
Observation of medication administration on June 27, 2022, at 9:30 a.m. revealed one nurse being reminded to wear a face shield, however, no face shield was immediately available.
Observation of physician arriving at facility on June 28, 2022, revealed the physician attempting to walk past the reception desk wearing a surgical mask. The physician was stopped at that time and was required to go through the facility's screening process. The physician did not have an N95 mask or face shield and heard to inquire as to why these items were required since the physician visits at least two times per week and was not required to wear them previously.
Observation on June 29, 2022, at approximately 8:30 a.m. of the facility parking lot revealed a resident ambulating in the parking lot with a therapy department employee. The resident was not wearing a face mask and the therapy department employee was wearing an N95 mask which was pulled down below the employee's chin.
Observation on all days of the survey of the front porch area in the afternoon revealed all residents on the porch were not wearing face masks.
The above information was conveyed to the Nursing Home Administrator and the Director of Nursing on June 29, 2022 at 12:05 p.m.
The facility failed to maintain the PPE requirements that were set forth by the facility to prevent the spread of Covid-19.
28 Pa. Code 201.18(b)(1)(2)(3) Management
| ||Plan of Correction - To be completed: 07/28/2022|
1. Employees E4, E5, and physician were immediately educated on proper use of PPE.
2. Residents did not suffer ill-effects from employees not using proper PPE. Facility completed baseline audit to ensure infection control policies were in place and up to date.
3. Facility implemented immediate infection control plan of daily huddles for each shift to make staff aware of current PPE and COVID 19 protocols for the area they are working. Facility will educate all staff regarding infection control related to appropriate PPE for COVD 19 zones to ensure professional standards necessary for proper infection control by July 21st 2022.
4. A root cause analysis will be completed and submitted to QAPI committee by July 21st 2022.
5. The leadership team will conduct daily rounds throughout the facility to ensure the appropriate infection control procedures for infection control related to appropriate PPE for COVID 19 nursing units are being performed by all appropriate staff on each unit. Ad hoc education will be provided to persons who are not correctly utilizing proper infection prevention/control practices.