§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 observation and staff interview, it was determined that the facility failed to maintain linens in a sanitary manner in the facility's main linen supply storage area.
Findings include:
In an interview with Employee 6, Assistant Director of Nursing, on January 12, 2024, at 11:30 AM, Employee 6 indicated the facility does not complete any laundering of linens or resident items in the facility and items were sent out of the facility to be laundered.
In a concurrent observation of the area, clean linens and laundry are returned to the facility that Employee 6 revealed to be an area through a door in the back service hallway of the facility. Upon entering the door, a storage area behind a metal cage was observed on the left, which contained mattresses and multiple other items. Just past the cage area on the left was a man observed working at a table, multiple tools and equipment were observed in the area, which Employee 6 confirmed was the "maintenance shop area." On the left side of the other room after the "maintenance shop area," not separated by any walls or rooms, only shelving of maintenance tools and supplies, were several large bins on wheels containing various linens such as towels, wash cloths, blankets, and sheets. Four of the bins containing blankets and towels, were observed stacked 12-18 inches above the top of the bin. A black cover was observed lying over the very top portion of the items completely exposing the linens on all sides until reaching the level that was inside the bin.
The bins of linens noted above were also located within 10-20 feet of a set of double doors, which opened to the exterior of the building. During the observation with Employee 6, an employee of the facility was observed entering through the doors and walking past the exposed bins of linens.
In a concurrent interview and observation with Employee 7, environmental services, Employee 7 indicated the clean linens are all delivered through the observed double doors and that extra linens were ordered due to a long holiday weekend. Employee 7 indicated that the linens should have all been covered. During the interview with Employee 7, an additional employee was observed entering through the double doors noted above. Employee 7 indicated staff of the facility do enter and exit through the doors located in front of the exposed linen.
The above findings regarding the storage of linens were reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant, on January 12, 2024, at 12:05 PM.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 205.26 (d) Linen Storage
| | Plan of Correction - To be completed: 02/20/2024
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 resident harm identified. 2. The stock clean linens were moved to a location away from high traffic areas with walls and a door. 3. The housekeeping manager or designee will educate housekeeping staff on keeping all stock clean linens covered. 4. Weekly audits of covering stock clean linens will be completed weekly x4 then monthly x2 with results reported in QAPI. 5. Compliance by February 20, 2024
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