Non-compliance with Act 52 Infection Control Plan
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The current infection prevention and control policy, last reviewed in December 2024, was found to be lacking in several areas. The policy is intended to prevent, identify, control, and reduce the risk of infections among employees, volunteers, visitors, and contract healthcare workers. However, it did not include all the necessary components as mandated by Act 52, such as a multidisciplinary committee involving various staff members and community representatives, effective measures for detecting and controlling healthcare-associated infections, and protocols for handling MRSA and MDRO exposures. During the survey, it was confirmed by the infection preventionist that the facility's infection control policy did not meet all the requirements of Act 52. Additionally, there was no evidence of infections being reported to the state reporting agency since May 2024, which is a requirement under Act 52. This lack of compliance indicates a significant gap in the facility's infection control measures, potentially affecting the health and safety of residents and healthcare workers.
Plan Of Correction
PA-PSRS is now current. To identify residents with the potential to be affected, DON/designee will complete an audit of the last 30 days of the requirements of ACT52 to ensure requirements are met. To prevent re-occurrence, DON/designee will educate ADON/IP on requirements of ACT52. To monitor and maintain compliance, DON/designee will audit submission of data to PA-PSRS monthly x 4 to ensure requirements are met. All results will be brought to the QAPI committee.
Penalty
The facility did not ensure that all required nine multidisciplinary members, including the Medical Director, lab, and pharmacy representatives, attended quarterly Infection Control Committee meetings for three of four quarters, as confirmed by meeting logs and the DON.
The facility did not include pharmacy or laboratory personnel in its infection control committee meetings, as required by the Act 52 Infection Control Plan. Attendance records for QAPI meetings showed no evidence of participation from these disciplines, despite regulatory requirements for a multidisciplinary committee.
The facility failed to comply with the Act 52 Infection Control Plan by not providing evidence of infection control committee meetings and attendance. Despite repeated requests from the surveyor, the facility did not demonstrate adherence to the plan's requirements, which include having a multidisciplinary committee with representatives from various departments.
The facility failed to ensure the presence of required multidisciplinary members at Infection Control Committee meetings for four quarters and did not hold meetings for six months. This was confirmed by staff interviews and attendance records, indicating non-compliance with the MCARE Act.
The facility failed to ensure all required multidisciplinary members attended the Infection Control Committee meeting for one quarter, did not report healthcare-associated infections for two months, and did not provide timely written notifications to residents or families. These deficiencies were linked to a transition in the Infection Preventionist role, resulting in reporting access issues.
The facility failed to ensure that its Infection Control Committee meetings included all required multidisciplinary members for four consecutive quarters. Key members such as the medical director, infection preventionist, lab, and pharmacy representatives were absent from meetings, violating the MCARE Act's requirements.
Infection Control Committee Lacked Required Multidisciplinary Attendance
Penalty
Summary
The facility failed to ensure that all required nine multidisciplinary members were present at the quarterly Infection Control Committee meetings for three out of four quarters. Specifically, attendance records for the first, second, and third quarterly meetings showed that the Medical Director, a laboratory representative, and a pharmacy representative were not present at various meetings. The facility's policy requires a risk assessment using an all-hazard approach to prioritize infection prevention and control activities, and these meetings are intended to support that process. Interviews with the Director of Nursing confirmed that the required members were not in attendance for the specified quarters. The absence of these key members was documented in the meeting attendance logs, and the deficiency was acknowledged by facility leadership during the survey process. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
Required signatures couldn't be obtained since meetings have passed. Infection preventionist will have the Medical Director, lab, and pharmacy attend 1 meeting each quarter of the year. Director of Nursing or Designee will educate all team members of Infection Prevention on required meeting attendance. Director of Nursing or designee will audit the Infection Control meetings to assure all required attendance is met quarterly. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Include Required Disciplines in Infection Control Committee
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements outlined in the Act 52 Infection Control Plan. Specifically, the facility did not include representatives from pharmacy or laboratory personnel in its infection control committee meetings, as required by regulation. Documentation provided by the facility, titled "QAPI (Quality Assurance and Performance Improvement) Attendance," was reviewed for several meeting dates, but there was no evidence or signatures indicating that pharmacy or lab staff attended any of these meetings. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that infection control meetings were held during QAPI meetings on a quarterly basis or more frequently if needed. However, attendance records for these meetings did not show participation from pharmacy or laboratory personnel, which is a required component of the multidisciplinary infection control committee. No information about specific residents or their medical conditions was included in the report.
Plan Of Correction
1. Facility is unable to retroactively correct deficiency for past Act 52 meetings. 2. An employee of the Pharmacy and a Representative from the Laboratory have been invited to the next QA/Act 52 meeting. 3. All attempts will be made to ensure all appropriate members are present and will facilitate via phone conference if necessary. The Administrator and DON will be educated on which members of the multidisciplinary committee need to be present for QA/Act 52 meetings. 4. Monthly sign-in sheets for QA/Act 52 will be reviewed to ensure all appropriate members of QA/Act 52 meeting was present monthly and results will be forwarded to QA meeting to ensure ongoing compliance.
Non-Compliance with Infection Control Committee Requirements
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. This plan mandates that a health care facility develop and implement an internal infection control plan aimed at improving the health and safety of residents and health care workers. The plan should include a multidisciplinary committee with representatives from various departments, such as medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, members from the infection control team, and community representatives. However, the facility was unable to provide evidence of the infection control committee meetings and attendance records since the last standard survey. During interviews with the Nursing Home Administrator and the Director of Nursing, who also serves as the facility's infection preventionist, the surveyor requested documentation of the infection control committee meetings. Despite repeated requests, the facility did not provide the necessary evidence, indicating a failure to adhere to the infection control plan's requirements. This deficiency highlights the facility's non-compliance with the established standards for infection control, as outlined in the Act 52 Infection Control Plan.
Plan Of Correction
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 individual resident was identified as impacted. 2. A multidisciplinary committee is being assembled that meets the requirements of Act 52, and a meeting will be scheduled to be held at least quarterly. 3. The Regional Director of Operations will educate the current NHA on the need to assemble a multidisciplinary committee that meets the requirements of Act 52, and that a meeting is to be scheduled and held on a quarterly basis. 4. The Regional Director of Operations will audit to ensure that a multidisciplinary committee that meets the requirements of Act 52 is in place, and that a meeting was scheduled and held on a quarterly basis. Audit findings will be reviewed at the QAPI meeting.
Infection Control Committee Deficiencies
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility did not ensure that the Infection Control Committee meetings included the nine required multidisciplinary members, such as a community member and a patient safety officer, for four consecutive quarters. Additionally, the facility did not hold Infection Control Committee meetings for six months spanning from October 2024 to March 2025. These deficiencies were confirmed through staff interviews and a review of the facility's Infection Control Committee attendance records. During interviews, both the Infection Preventionist RN and the Nursing Home Administrator acknowledged the absence of the required multidisciplinary members at the Infection Control meetings and the failure to conduct these meetings for the specified months. The lack of compliance with the infection control plan as outlined in the MCARE Act indicates a significant oversight in maintaining the health and welfare standards for residents, as mandated by federal and state regulations.
Plan Of Correction
1. Facility will have required attendees for quarterly Infection Control meetings. 2. NHA to educate DON/designee of required Infection Control attendees. 3. DON/designee to educate all required attendees and attendance requirements. 4. DON/designee to audit Infection Control meeting required attendees and notification to resident/resident representative of acquired healthcare associated infections while at the facility monthly x 6 months.
Infection Control Deficiencies and Reporting Failures
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by state regulations and the MCARE Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Committee meeting for one of the four quarters, as the laboratory member was absent during Quarter Four. Additionally, the facility did not report healthcare-associated infections for January and February 2025, despite having recorded six infections in January and seven in February. This failure was attributed to the transition of the Infection Preventionist role, where the new Regional Clinical Director-Infection Preventionist did not have the necessary access to report these infections. Furthermore, the facility did not provide written notification to residents or their family members within seven days of a healthcare-associated infection for the months of January and February 2025. This lack of communication was confirmed by the Infection Preventionist, who acknowledged that no letters had been sent to the residents or their families during this period. These deficiencies highlight the facility's non-compliance with the MCARE Act's requirements for infection control and timely communication with residents and their families.
Plan Of Correction
Moving forward, the facility will ensure that the required multidisciplinary members are present at the Infection Control meeting. The facility will report health care associated infections monthly and will provide written notification to the resident/family member of a healthcare-associated infection. To prevent this from recurring, the RVPO/RDCS educated the IP on requirements of 1020 and the responsibility of the licensee. The facility will ensure the appropriate team members are present at the meetings. To monitor and maintain ongoing compliance, the RDCS/designee will audit infection control/PASRS reporting weekly for 4 weeks, then monthly for 2 months. Negative findings will be addressed, and ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Infection Control Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that its Infection Control Committee meetings included all required multidisciplinary members for four consecutive quarters. According to the Medical Care Availability and Reduction of Error (MCARE) Act, the infection control plan must include a multidisciplinary committee with representatives from various departments, including medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, a community member, and a member of the infection control team. However, the facility's attendance records revealed that key members were consistently absent from these meetings. In the first quarter, the medical director was not present at the Infection Control Committee meeting. In the second quarter, the pharmacy representative was absent. The third quarter saw the absence of the medical director, infection preventionist, lab, and pharmacy representatives. Finally, in the fourth quarter, the pharmacy representative was again not in attendance. These absences indicate a failure to comply with the required composition of the infection control committee as mandated by the MCARE Act.
Plan Of Correction
1. Infection control data for quarters 1 and 3 2024 was reviewed by the medical director. Data from quarters 2, 3 and 4 2024 was reviewed by the consultant pharmacist. Data from quarter 3 2024 was reviewed by the infection preventionist and lab personnel. 2. An audit was done of 2024 infection control committee logs to ensure all other required persons were in attendance. 3. Director of nursing or designee will in-service all persons required for infection control committee meetings on meeting scheduled and required attendance. 4. Director of nursing or designee will audit attendance sheets quarterly to ensure all required persons are in attendance. Audit findings will be shared with QAPI committee.
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