Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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LITTLE FLOWER MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on July 30, 2020. The facility was in compliance with 42 CFR 483.73 related to E-0024(b)(6).

 Plan of Correction:

Initial comments:
Based on the findings of a COVID-19 Focused Infection Control Survey which was completed on July 30, 2020, at Little Flower Manor was found to be not in compliance with 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensing Regulations as they relate to the Health portion of the survey process and has not implemented the CMS and Center for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

 Plan of Correction:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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.

Based on review of professional literature, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to implement infection control standards of practice after one out of one new confirmed case of COVID-19 at the facility. (Employee E4)

Findings include:

Review of the Pennsylvania Department of Health, "Update: Testing Guidance for COVID-19 in Long-Term Care Facilities Residents and Healthcare Personnel," 2020-PAHAN-509-5-29-UPD, dated May 29, 2020, revealed that, "If there is a new confirmed case of COVID-19 in any HCP (healthcare personnel, including nurses, nursing assistants and administrative personnel) or any facility-onset SARS-CoV-2 (COVID-19) infection in a resident the following testing should be implemented: Test all residents and HCP in the facility even if baseline testing has been completed in the past; if testing capacity is limited, DOH (the Department of Health) recommends testing residents and HCP on the same unit or floor of a new confirmed case." Continued review revealed, "After testing all residents and HCP in response to a new case, DOH recommends follow-up testing to ensure transmission has been terminated as follows: Immediately test any resident or HCP who subsequently develops fever or symptoms consistent with COVID-19; continue repeat testing of all previously negative residents once per week until the testing identifies no new cases of COVID-19 among residents or HCP through at least one 14-day incubation period since the most recent positive result; continue repeat testing of all previously negative HCP at least once a week until testing identifies no new cases of COVID-19 among residents or HCP through at least one 14-day incubation period since the most recent positive result."

Review of the Pennsylvania Department of Health, "Interim Guidance for Skilled Nursing Facilities During COVID-19" dated July 20, 2020, revealed that, "An 'Outbreak' means either of the following: A staff person who tests positive for COVID-19 and who was present in the facility during the infectious period. The infectious period is either 48 hours prior to the onset of symptoms or 48 hours prior to a positive test result if the staff person is asymptomatic; Or new facility onset of COVID-19 case or cases." Continued review revealed that prior to reopening, the facility must develop a Reopening Implementation Plan which, "Includes the capacity to administer COVID-19 diagnostic test to all residents and staff if the facility experiences an outbreak."

Review of facility policy, "COVID Testing of Residents and Staff" dated revised July 29, 2020, revealed that, "If an employee tests positive, that employee will be referred to Occupational Health; Contract tracing will be done to identify the residents who were possibly exposed and testing will be conducted."

Review of the facility's "Reopening Plan" dated July 20, 2020, revealed that, "We test all staff, residents and patients, with or without symptoms, when deemed medically necessary and in accordance with the guidelines of the Pennsylvania Department of Health and the Centers for Disease Control and Prevention."

Review of facility documentation submitted by the Infection Control Nurse on July 27, 2020, revealed that an employee was tested on July 20, 2020, for COVID-19 as part of surveillance testing. "The test result was positive ...Contract tracing done. Residents who were potentially exposed and their family members were notified and these residents were tested."

In an email communication, dated July 29, 2020, at 3:12 p.m., the Nursing Home Administrator (NHA) provided a written statement with the details of the above reported COVID-19 positive employee. On July 23, 2020, the facility received notification from the laboratory that Employee E4, a nursing assistant, tested positive for COVID-19. The employee had been tested on July 20, 2020. In the statement, the NHA wrote, "As of July 23, 2020, we did not have enough testing supplies in the building to test all the staff and the residents, so we initiated contract tracing on the residents to whom Employee E4, nursing assistant provided care." The facility tested 23 residents as a result of their contract tracing. Additionally, two staff members reported symptoms and were tested.

Interview on July 29, 2020, at 2:00 p.m. with the NHA and the Infection Control Nurse revealed that Employee E4, nursing assistant worked on the A and B wings. Both the NHA and Infection Control Nurse confirmed that COVID-19 testing was not conducted for all the previously negative residents and staff on the A and B wings in response to Employee E4's positive COVID-19 result. Further, the NHA confirmed that the facility did not test any of the staff that Employee E4 worked with during the infectious period.

Review of nursing staffing schedules revealed that Employee E4, nursing assistant worked at the facility during the 3-11 shift on: July 18, 19, 20 and 22, 2020.

Interview on July 30, 2020 at 12:50 p.m., the NHA confirmed that the facility did not test all residents and staff once a new case of COVID-19 was identified at the facility. The NHA stated that she would need 254 tests in order to test all residents and staff and that the facility did not have that many tests available.

The facility failed to implement infection control standards of practice after a new confirmed case of COVID-19 at the facility.

28 PA Code 201.14(a) Responsibility of licensee

 Plan of Correction - To be completed: 08/17/2020

Employee E4 self-quarantined and remained asymptomatic.
Potentially exposed residents and staff were tested or monitored as indicated based upon availability of testing capacity at the time. No new positive cases were identified. More than 14 days have elapsed and no new cases of Covid-19 have been identified in staff or residents.
The Director of QI and Infection Control reeducated staff about testing requirements for Covid-19.
The facility has procured additional testing supplies. These supplies will be monitored weekly to maintain adequate par levels for future testing needs.
The Infection Preventionist, Director of Nursing and Nursing Leadership will ensure that testing requirements are implemented as recommended by the Department of Health and CDC. The Director of Quality Improvement will audit resident line listings and staff screenings weekly for one month, monthly for two months and quarterly thereafter. The results of these audits will be presented to the QAPI team for further recommendations as indicated.

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