|§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.
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 infection control surveillance documentation, observation, and staff interview, it was determined that the facility failed to implement proper visitor and staff screening measures related to COVID-19.
Review of the Centers for Medicare and Medicaid Services QSO-20-39-NH memo revised on March 10, 2022, indicated facilities should screen all who enter for temperature and signs and symptoms of COVID-19, as a core principle of COVID-19 infection prevention.
Upon entrance to the facility on May 22, 2022, at 9:25 AM observation of the main entrance revealed that there was a COVID-19 screening log/binder for staff and visitors to complete upon entry to the facility. One of the entry logs was a request for the person's temperature. There was no thermometer available at the time of the survey team's entrance to facilitate an appropriate COVID-19 screening prior to entry to the facility. The survey team was permitted to enter the building without having their temperature(s) screened.
Concurrent review of the facility's COVID-19 screening log/binder from May 9, 2022, until current revealed that of the 199 COVID-19 screening entries, 37 of them failed to indicate that a temperature screening was completed and/or documented and seven of them failed to indicate if they had any signs and symptoms of COVID-19 at the time of entry to the facility.
Observation of the main entrance of the facility on May 22, 2022, at 9:46 AM revealed that a thermometer was now located near the COVID-19 screening log/binder.
In an entrance interview with Employee 5, registered nurse, regional nurse consultant, on May 22, 2022, at 10:00 AM and during an interview on May 23, 2022, at 12:51 PM with Employee 1 registered nurse, regional nurse consultant, the two employees acknowledged the above findings.
The facility failed to properly screen staff and visitors to prevent or contain COVID-19 in the facility.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited deficiency 7/27/21 and 5/26/21
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
| ||Plan of Correction - To be completed: 06/14/2022|
1. The facility cannot retroactively correct the identified failures of the 37 temperature screenings and the 7 identified failures to indicate if they had any signs or symptoms of COVID-19 at the time of entry into the facility.
2. No evidence exist that any residents having any potential to be affected by this deficient practice.
3. The Director of Nursing/Infection Control Preventionist reviewed, implemented, and will monitor effective policies/procedures to ensure infections are prevented, treated, and/or controlled in accordance with the latest CDC and/or CMS guidelines.
Staff will receive re-education on the appropriate screening process and requirements for completion of log in sheets.
The facility conducted a Root Cause Analysis and took the appropriate actions to secure the signing-in process to include:
-Login form amended to included highlighted column titles to bring to the attention the requirements of those completing the form.
-New signage and login area created.
-Permanent thermometer is in place to ensure availability of the necessary tools.
-A letter is being sent to families and/or responsible parties reminding them of the importance of signing into the facility when visiting residents within the facility.
4. The Nursing Home Administrator/designee will perform audits on the "Log-In" sheets daily for 4 weeks to ensure accurate use of the available tools and to ensure compliance with the guidelines for visitor/staff screening related to COVID-19.
Results of the audits will be reported to the Quality Assurance and Performance Improvement Committee who will determine the necessity of continued audits.