§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 select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for one of 22 residents reviewed (Resident 101), implement appropriate transmission based precautions (TBP) for one of one resident reviewed on TBP (Resident 96), and ensure an environment free from the potential spread of infection with the storage of resident supplies on one of five nursing units (200; Residents 62 and 77).
Findings include:
The facility policy entitled "Isolation, Transmission Based Precautions," last reviewed without changes on May 22, 2024, revealed standard precautions will be used when caring for residents. Transmission based precautions will be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. If a resident is suspected of, or identified as having a communicable infectious disease, the registered nurse supervisor will notify the infection control designee and the resident's physician for appropriate transmission-based precautions. Transmission based precautions will remain in effect until the physician or infection control designee discontinues them. Contact precautions will be used in addition to Standard Precautions for residents with specific infections that can be transmitted by direct and indirect contact.
Clinical record review for Resident 96 revealed the facility admitted him on October 21, 2024. Review of Resident 96's physician orders revealed an order dated April 7, 2025, for contact isolation due to a shingles rash on his face and neck.
Nursing documentation dated April 8, 2025, at 5:15 AM revealed Resident 96 began on the medication Valtrex (an antiviral medication) related to his diagnosis of shingles. Documentation revealed a pustule rash continues on Resident 96's face, and down the right side of his neck with pustules remaining intact. Contact precautions remain in place. When the rash is still blistered and contains fluid in the blisters, the person is considered contagious if the rash comes in close contact to someone else, so it is best to keep the rash covered.
Observation of Resident 96 on April 8, 2025, at 10:12 AM revealed he was in the dining/activity room seated at a table with 11 other residents making Easter eggs. The shingles rash was observed on his face and neck. The shingles rash on Resident 96's neck was exposed with pustules. Resident 96's rash was not covered.
Observation of Resident 96 on April 9, 2025, at 10:25 AM revealed he was walking on the unit holding hands with another resident (Resident 96's wife). The shingles rash on Resident 96's neck was again exposed with pustules. Resident 96's rash was not covered. Observation of Resident 96 on April 9, 2025, at 12:29 PM he was in the dining room eating lunch, with two other residents seated at his table.
Resident 96 was unable to be interviewed regarding any education he received regarding his rash and contact precautions due to his current cognitive status.
Interview with Employee 1, infection control nurse, on April 10, 2025, at 2 PM confirmed these findings. She stated that staff should have covered Resident 96's rash on his neck with the exposed pustules.
An observation of Resident 62's bathroom on April 8, 2025, revealed a bag of bladder pads stored directly on the floor beside the toilet.
An observation of Resident 77's bathroom on April 8, 2025, revealed a plastic bag of maxi pads stored directly on the floor beside the resident's toilet.
The above information regarding Residents 62 and 77 was reviewed with the Nursing Home Administrator and Director of Nursing on April 10. 2025, at 2:30 PM.
Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, "Enhanced Barrier Precautions in Nursing Homes," dated March 20, 2024, revealed that CMS was issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. In 2019, CDC (Centers for Disease Control) introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP). In July 2022, the CDC released updated EBP recommendations for "Implementation of PPE Use in nursing homes to prevent spread of MDROs." The CDC's, "Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs)," stipulated that, "When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves." Nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.
Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, revealed that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. CDC has created examples of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions. Facilities can use these signs or modify them to create signs that work for their facility.
Review of CDC guidance at https://www.cdc.gov/long-term-care-facilities/media/pdfs/Observations-Tool-for-Enhanced-Barrier-Precautions-Implementation-508.pdf, Enhanced Barrier Precautions (EBP) Implementation-Observations Tool (For use in Skilled Nursing Facilities/Nursing Homes only) reiterated that signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. The EBP sign should also include a list of the high-contact resident care activities for which PPE (gown and gloves) should be worn. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure EBP are followed. Signs should not include information about a resident's diagnosis or the reason for the use of EBP (e.g., presence of a resistant germ, wound).
A review of the CDC sign for EBP revealed that the first directive is that everyone must clean their hands, including before entering and when leaving the room.
Review of the facility's policy entitled, "Enhanced Barrier Precautions," last reviewed without changes May 22, 2024, revealed that the compliance guidelines included that the facility would have the discretion on how to communicate to staff which residents require the use of EBP. The implementation of EBP included to make gowns and gloves available near or outside the resident's room, ensure alcohol-based hand rub is in every resident room, position a trash can and linen cart inside the resident room near the exit, the infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education, and provide education to residents and visitors.
The facility policy did not include the implementation of the placement of signage visible to individuals entering the room to signal the specific actions they should take to protect themselves and the resident.
Clinical record review for Resident 101 revealed a physician's order dated March 28, 2025, for staff to implement enhanced barrier precautions related to an indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine).
Observation of Resident 101's room on April 9, 2025, at 10:18 AM revealed that her door was partially shut. There was no signage or indication before entering her room of the implementation of enhanced barrier precautions.
Interview with Employee 2 (registered nurse) on April 9, 2025, at 10:33 AM revealed that the sign that indicated Resident 101 required EBP was positioned on the inside of Resident 101's door and was not visible to any person before entering her room. The interview confirmed that the sign positioned on the inside of Resident 101's door was the CDC Enhanced Barrier Precautions sign that included the directive that, "Everyone must clean their hands, including before entering and when leaving the room."
Interview with the Nursing Home Administrator on April 10, 2025, at 10:00 AM confirmed that the facility's EBP policy did not include the necessity of signage to notify staff and/or visitors that EBP were necessary.
Interview with the Nursing Home Administrator and the Director of Nursing on April 10, 2025, at 10:35 AM confirmed that the facility policy did not include an expectation that staff would post a sign visible to individuals entering the room to signal the specific EBP actions they should take to protect themselves and the resident. The interview also confirmed that the facility policy did not include how the facility would provide education to residents and visitors regarding EBP requirements. The interview indicated that "generally" Employee 1 (assistant director of nursing/infection preventionist) ensures that a sign is posted. The Director of Nursing stated that she believed that current nationally accepted standard guidance regarding EBP did not require the use of a sign.
The surveyor referred the Director of Nursing and the Nursing Home Administrator to the CDC and CMS guidance noted above.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 05/27/2025
Facility cannot retroactively correct implementation of signs for EBP for resident 101. Resident 101 discharged from facility. Transmission based precautions have been discontinued for residents 96 due to resolution of condition. Items stored on the floor for residents 62 and 77 were moved and appropriately stored.
Signage for residents with EBP have been moved to the outside of the door. There are currently no other residents on contact precautions. Resident rooms will be checked to ensure proper storage of personal hygiene products.
The policy for EBP will be updated to reflect the use of signage and its placement. Nursing staff will be educated on policy change, maintaining contact precautions and storage of personal hygiene products.
An audit of sign placement for residents on EBP will be completed weekly x 4 weeks. An audit for contact precautions compliance will be completed weekly x 4 weeks. Random audits of resident rooms for storage of personal hygiene products will be completed weekly x 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
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