Elderwood at Wheatfield
March 15, 2021 Covid19 Survey

Standard Health Citations

COVID-19 TESTING-RESIDENTS & STAFF

REGULATION: §483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: §483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: (i) Testing frequency; (ii) The identification of any individual specified in this paragraph diagnosed with COVID-19 in the facility; (iii) The identification of any individual specified in this paragraph with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19; (iv) The criteria for conducting testing of asymptomatic individuals specified in this paragraph, such as the positivity rate of COVID-19 in a county; (v) The response time for test results; and (vi) Other factors specified by the Secretary that help identify and prevent the transmission of COVID-19. §483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests; §483.80 (h)((3) For each instance of testing: (i) Document that testing was completed and the results of each staff test; and (ii) Document in the resident records that testing was offered, completed (as appropriate to the resident’s testing status), and the results of each test. §483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19. §483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing services under arrangement and volunteers, who refuse testing or are unable to be tested. §483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state and local health departments to assist in testing efforts, such as obtaining testing supplies or processing test results.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2021
Corrected date: May 14, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the COVID-19 Infection Control Focused Survey completed on 3/15/21, the facility did not ensure facility staff, including individuals providing services under arrangement, were tested and documented that testing was complete with the results of each test for COVID-19 that is consistent with current infection control measures during staff testing for COVID-19. Specifically, for one (Licensed Practical Nurse (LPN) #1-a contract employee) of four employees reviewed, the facility had no documented evidence that COVID-19 testing was completed in accordance with Executive Orders. The finding is: On 8/25/20, the Centers for Medicare & Medicaid Services (CMS) published Interim Final Rule number CMS3401-IFC, titled Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. This interim final rule provided, at 42 CFR section 483.80(h): The LTC (Long Term Care) facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: (1) Conduct testing based on parameters set forth by the Secretary (of Health and Human Services), including but not limited to: (i) Testing frequency. The Centers for Medicare & Medicaid Services (CMS) guidance with Reference Number QSO-20-38-NH, dated 8/26/20, titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, documented: the facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. The CMS guidance further documented: An outbreak is defined as a new COVID-19 infection in any staff or resident, and For outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of 3 COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. New York State Executive Order (EO) 202.88, dated 1/4/21, documented: The directive contained in EO 202.73 which modified EO 202.30 and 202.40, requiring testing of nursing home staff as directed by the Commissioner of Health is hereby modified to authorize the Commissioner of Health to set forth testing of all personnel at such facility in any area of the state irrespective of location in a micro-cluster zone as provided in 202.68. The New York State Department of Health Dear Administrator Letter, NH-21-01, titled Nursing Home Staff Testing Requirements, dated 1/7/21, documented: Operators and administrators of all nursing homes are required to test or arrange for the testing of all personnel, including all employees, contract staff, medical staff, operators and administrators, for COVID-19 twice per week in all nursing homes. Review of the facility policy and procedure (P&P) titled COVID-19 Patient & staff Testing Methods and Requirements dated 03/05/2021 documented the facility will test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 as directed by state and federal requirements. The facility policy further stated if individual State Requirements differ, the more stringent will be followed. Review of [DIAGNOSES REDACTED]-CoV2 Rapid [MEDICATION NAME] and [DIAGNOSES REDACTED] COV-2 Nucleic Acid Detection Test (rt-PCR) report from 2/18/21 through 3/15/21 revealed that LPN #1 was tested on [DATE], 2/23/21, 3/3/21 and 3/9/21. LPN #1 did not have twice weekly COVID-19 test results for the weeks of 2/14/21-2/20/21, 2/21/21-2/27/21, 2/28/21-3/6/21 and 3/7/21-3/13/21. Additionally, LPN #1 did not have COVID-19 test results for the week of 2/7/21-2/13/21. Review of an untitled document, identified by the Director of Nursing (DON) as LPN #1's timesheets, dated 2/7/21 through 3/13/21 revealed: - week of 2/7/21-2/13/21, worked five shifts (2/9/21, 2/10/21, 2/11/21, 2/12/21 and 2/13/21) - week of 2/14/21-2/20/21, worked six shifts (2/14/21, 2/15/21,2/17/21, 2/18/21, 2/19/21 and 2/20/21) - week of 2/21/21-2/27/21, worked five shifts (2/22/21, 2/23/21, 2/25/21, 2/26/21 and 2/27/21) - week of 2/28/21-3/6/21, worked five shifts (2/28/21, 3/1/21, 3/3/21, 3/4/21 and 3/5/21) -week of 3/7/21-3/13/21, worked five shifts (3/8/21, 3/9/21, 3/10/21 3/11/21 and 3/13/21) Review of an untitled facility document, identified by the DON as the facility's weekly log for tracking staff COVID-19 testing, dated 2/3/21-3/9/21 revealed no evidence of COVID-19 testing dates or results for LPN #1 during this date range. During an interview on 3/15/21 at 2:10 PM, LPN #1 stated she worked for an agency and had signed a contract to work five 8-hour shifts a week for this facility. She stated she had been tested for COVID-19 only once a week at the facility. She stated that no one, supervisor or management staff, had ever told her she needed to be tested twice a week for COVID-19. During an interview on 3/15/21 at 1:52 PM, the DON stated it appeared that the testing was out of compliance for LPN #1. During further interview at 2:05 PM, the DON stated the facility's process for tracking staff testing was that the Human Resource (HR) Department was responsible to track the employee, including agency staff, testing dates and the test results. If a staff member was non-compliant and needed a COVID-19 test, HR sends an e-mail to the Scheduling Department and the employee's Department Director. The Scheduling Coordinator then sends a text message to the employee to inform them that they were out of compliance. The DON stated she was not aware LPN#1 was out of compliance with the testing requirements and expected the employee to be tested two times a week as required because she is working 5 shifts a week. The DON reviewed the facility tracking documentation for employee testing provided by the HR Department and stated LPN #1's name was not on the log and it should have been. During an interview on 3/15/21 at 2:12 PM, the Scheduling Coordinator stated she was not aware LPN #1 was not being tested for COVID-19 twice a week as required. She stated the HR Department Director would email her a list of employees that were delinquent in COVID-19 testing so she could send a text message to the employee. The Scheduling Coordinator stated she had not sent any messages to LPN #1 because she had not received any e-mails from HR that LPN #1 wasn't being tested and was not aware LPN #1 was out of compliance. The Scheduling Coordinator stated she informed LPN #1 of the testing requirements when she started her contract and would expect the employee to follow the testing guidelines of the facility. During an interview on 3/15/21 at 2:32 PM, the HR Department Director stated LPN #1 had previously worked at the facility through the agency and knew the facility's COVID-19 testing policies, therefore she expected the employee to get tested as required. The HR Department Director stated she adds the employee or agency staff to the tracking log after she received a COVID-19 test result because it's a log of those who had been tested . She stated she did not know when an agency staff is scheduled to work in the building. In addition, the HR Department Director stated she usually receives a COVID-19 test result from the agency prior to the employee starting but had not received a COVID-19 test prior to LPN#1 starting (MONTH) 9, 2021. During an interview on 3/15/21 at 2:44 PM, the Administrator stated if staff worked more than three shifts a week they should be tested for COVID-19 twice weekly as required to prevent COVID-19 from being brought into the facility and to protect the residents. The Administrator stated it is the responsibility of the DON and herself to ensure the agency staff are tested as required. During an interview on 3/15/21 at 2:48 PM, the Infection Preventionist (IP) stated staff are tested for COVID-19 to ensure they are not bringing COVID-19 into the building and exposing the residents. The IP stated she believed the HR department was tracking all staff COVID-19 testing including agency staff to ensure staff were tested as required. The IP further stated full time staff were to be tested twice weekly. 415.19(a)(1); 400.2

Plan of Correction: ApprovedMarch 29, 2021

F886 Corrective action to insure those residents found to be affected by the deficient practice as follows: 1) Will utilize new spreadsheet to ensure that all staff are tested per requirements. The spreadsheet will populate with staff names on hire. 2) LPN #1 was tested upon arrival for shift and was negative 3) LPN #1 was issued disciplinary action related to her non compliance with required testing. Systemic measures that were in place at time of survey and those put in place to ensure this practice does not reoccur: 1)Facility will continue to utilize a spreadsheet to keep track of tests completed by all staff including agency. 2) The facility implemented a new spreadsheet that is linked to the payroll system so new hires will be automatically entered onto tracking. 3) All staff including agency staff to receive in service on testing requirements and testing times. 4) Any staff found to be out of compliance will be advised of need for rapid test prior to next scheduled shift. Quality measures to ensure prevention of future deficient practice: 1) Director of Nursing or designee will review tracking sheet on daily basis forwarding copies to department heads for review of their staff member compliance. 2) An audit will be completed weekly x 2 months by the DON or designee ensuring staff compliance and need for any disciplinary follow up for non-compliance. 3) Audits will be reviewed immediately on completion and at quarterly QA to monitor for sustained resolution of issue The Administrator/DON will be responsible for overall monitoring, evaluation, and implementation of this plan. Completion date 5/14/21