Observations:
Based on the facility's infection control documents, clinical record review and staff interview, it was determined the facility failed to report to appropriate health agencies and the Division of Nursing Care Facilities field office reportable diseases for 13 of 13 residents sampled.( Residents 1,2,3,4,5,6,7,8,9,10,11,12 and 13).
Findings include:
A review of facility infection control documentation revealed the following residents tested positive for Influenza A on:
December 27, 2024, Resident 1
January 5, 2025, Resident 2
Resident 3
Resident 4
Resident 5
Resident 6
January 6, 2025 Resident 7
Resident 8
January 8, 2025 Resident 9
Janaury 9, 2025 Resident 10
January 10, 2025 Resident 11
January 16, 2025 Resident 12
January 18, 2025 Resident 13
An interview January 24, 2025 at 12 P.M., with the facility Infection Control Practioner and the Director of Nursing confirmed the mandated State agency's were not notified of the above positive Influenza cases in the facility.
| | Plan of Correction - To be completed: 02/08/2025
4550
Preparation and/or constitution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
The Administrator corrected the deficiency by reporting the influenza cases to the DOH on 12/27/24 at 0800, Event Number: 1066952.
The Infection Control Nurse, Director of Nursing, Administrator, and Assistant Administrator reviewed and were educated on the PA regulations regarding ERS reporting requirements.
§ 27.21a. Reporting of cases by health care practitioners and health care facilities. (2) Influenza is reportable within 5 working days after being identified by symptoms, appearance, or diagnosis.
Examination of the prior 24-hour clinical report and the daily Interdisciplinary Clinical Team Meeting will discuss any residents who exhibit signs of influenza, e.g., fever, chills, cough, sore throat, rhinorrhea, muscle/body aches, headaches, fatigue, vomiting, or diarrhea, and the need for diagnostic testing. If diagnosis is confirmed, treatment, isolation, and state reporting within 5 working days will be completed.
Facility follows the Infection Control Guidance set for by the Centers for Disease Control and Prevention.
The Infection Control Nurse has created a log of any reportable diseases, infections, and conditions. An additional checkbox will be added to the Infection Preventionist's Infection Control Log to indicate any reportable diseases have been or need to be submitted to the Department of Health.
Infection Control and Nursing Administration reviewed all cases; there were no additional reportable events required.
The Infection Preventionist will report monthly x three months to QAPI to ensure regulatory compliance in reporting infectious diseases has been met. The Infection Preventionist's log will be reviewed by QAPI team and the Administrator to ensure reporting requirements have been met.
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