§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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment in three of three soiled utility rooms.
Findings include:
The facility's policy for Infection Control, dated January 2, 2024, indicated that the facility is committed to preventing adverse outcomes such as health care associated infections and their related events, improving resident care by supporting the staff in all areas of the facility, minimizing occupational hazards associated with the delivery of healthcare, and fostering evidence-based decision making. The goal of the program is to provide a safe and sanitary environment.
The facility's policy for the laundry process, dated January 2, 2024, indicated that proper laundry processing is done to ensure resident and facility linen items are correctly cleaned and stored.
Observations of the facility's three separate utility rooms revealed that the rooms were full of soiled linen bags thrown on the floor.
Interview with Laundry Attendant 1 on February 24, 2024, at 9:38 a.m. confirmed that all three laundry rooms were filled with soiled linen and resident personal laundry. She stated that the facility's washer and dryer have not been working and that the laundry was behind.
Interview with the Regional Clinical Consultant on February 24, 2025, at 1:52 p.m. confirmed that resident laundry should be returned to the residents timely and revealed that there were negotiations at this time to have facility laundry sent out to be laundered. She confirmed that all three soiled utility rooms were filled with dirty linens and residents' personal laundry and that it was not sanitary.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 03/25/2025
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of the deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of federal and state law.
1. Immediate Corrective Action: The facility has immediately removed all soiled linen bags from the floor in the soiled utility rooms, and the soiled linens have been properly laundered. The areas were disinfected to ensure a safe environment.
2. Corrective Action Plan: The facility's washer and dryer are functional. The facility is in the process reviewing outside laundry services versus in-house laundry alternatives. Final outcome will be based on a thorough evaluation of options. In the interim, in-house laundry services will continue with added additional staffed shifts.
3. Staff Education and Communication: The Environmental Services Director/Designee will conduct training sessions with laundry staff, and the Director of Nursing will conduct training sessions with nursing staff to ensure compliance with handling and storage of soiled linens. This training will begin on 3/10/2025 and will be repeated as needed. Additionally, signage has been posted in the soiled utility rooms to reinforce the policy of not placing soiled linen bags on the floor. Staff will be required to sign an acknowledgment of the training and signage.
4. Ongoing Monitoring and Audits: The Environmental Services Director/Designee will conduct random audits of the soiled utility rooms three times per week for four weeks, then weekly for an additional four weeks, to ensure compliance with the policy of not placing soiled linen bags on the floor. If any noncompliance is identified, corrective actions, including re-education and retraining of staff, will be immediately implemented. Audit results will be forwarded to the Quality Assurance and Performance Improvement (QAPI) Committee for further review and action.
5. Preventative Measures and Sustainability: To ensure continued compliance, periodic re-education will be incorporated into routine staff training programs. Audits will continue at a frequency determined by the Quality Assurance and Performance Improvement (QAPI) Committee to ensure the ongoing effectiveness of these corrective measures.
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