A COVID-19 Focused Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/10/20 and 12/11/20. The facility was found to be in compliance with 42 CFR 473.83 related to E-0024 (b)(6).
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) on 12/10/20 and 12/11/20. The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Survey Census: 38
Sample Size: 5
The findings of the COVID-19 Focused Infection Control revisit survey conducted on 5/24/20. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP), completed specialized training in infection control prevention, which had the potential to affect 38 of 38 residents residing in the facility.
Findings include:
On 12/10/20 at 10:03 AM, an interview in the conference room with the Infection Preventionist, indicated she had not completed specialized training for infection control. The IP revealed she had started the training, but that she had gotten too busy at work to complete the program.
On 12/10/20 at 10:30 AM, an interview with the Administrator indicated the facility's IP had not had infection control specialized training because they have been busy with COVID-19 related issues. The Administrator revealed the IP should have specialized training and it will be completed as soon as possible.
On 12/11/20 at 10:20 AM, an interview in the conference room with the Director of Nursing Services (DNS) revealed the IP had been in her position since early June and the IP had not had time to complete infection prevention specialized training. The DNS indicated she was aware of the mandatory infection control training and that the facility's IP should have specialized training in infection control.
On 12/11/20 at 3:00 PM, in the conference room, the DNS provided the policy entitled, "Infection Preventionist," dated 1/10 and revised 10/17. The DNS revealed this is the policy the facility follows regarding the Infection Preventionist's roll. The policy was reviewed at this time and revealed no guidance on required training for Infection Preventionists.
¿483.80(b) Infection preventionist The facility has designated Leslie Pena LPN as the infection preventionist who is responsible for the facility's IPCP. ¿483.80(b)(1) Leslie Pena LPN has primary professional training in nursing. ¿483.80(b)(2) Leslie Pena LPN is qualified by education, training, experience and certification. ¿483.80(b)(3) Leslie Pena LPN work at full-time at the facility. ¿483.80(b)(4) Leslie Pena LPN has completed specialized training in infection prevention and control on 12/10/2020. ¿483.80 (c) Leslie Pena LPN IP participation on quality assessment and assurance committee. The individual designated as the IP is a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
