The Grand Rehabilitation and Nursing at Batavia
November 17, 2020 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2020
Corrected date: January 15, 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 11/17/20, the facility did not ensure residents and facility staff, including individuals providing services under arrangement and volunteers, 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 three (Licensed Practical Nurse (LPN) #1 and Certified Nurse Aides (CNAs) #2 and #3) of four contract employees reviewed for COVID-19 testing, the facility had no documented evidence of weekly COVID-19 test results during a facility COVID-19 outbreak. The finding is: 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. Review of the facility policy and procedure (P&P) titled [DIAGNOSES REDACTED] COVID-19 Testing guidelines effective 11/2020 documented staff will continue to be tested on ce weekly. If staff is tested off-site, proof and documented results must be presented. Facilities will continue to maintain records demonstrating compliance. Facilities will keep records of testing and results for one year. Review of the LTC Respiratory surveillance Line List provided by the facility for COVID-19 positive employees revealed one staff member tested positive for COVID-19 on 11/2/20. Review of the LTC Respiratory surveillance Line List provided by the facility for COVID-19 positive residents revealed two residents tested positive for COVID-19 on Unit B on 11/9/20. Review of the calendars for the contract agency titled The Grand at Batavia Nursing 4 week schedule ending 10/25/20 revealed: - LPN #1 worked 11/2/20 on Unit A, and 11/4/20 on Unit A double shift (16 hours). - CNA #2 worked 11/2/20 on Unit B, 11/3/20 on Unit A and 11/5/20 on Unit A. - CNA #3 worked 11/6/20 on Unit B, 11/8/20 on Unit A, 11/10/20 on Unit A, 11/12/20 on Unit A and 11/14/20 on Unit A Review of facility's untitled documents dated 8/25/20 through 11/13/20, that the acting Director of Nursing (DON) identified as used to track facility and contract staff weekly COVID-19 test results, revealed no documented evidence that LPN #1 and CNA #2 had COVID-19 tests completed prior to 11/6/20. There was no documented evidence that CNA #3 had a COVID-19 test completed at all. LPN #1 worked in the facility on 11/2/20 and 11/4/20 and CNA #2 worked in the facility on 11/2/20, 11/3/20, and 11/5/20 but they were not tested for COVID-19 until 11/6/20. CNA #3 worked in the facility on 11/6/20, 11/8/20, 11/10/20, 11/12/20, and 11/14/20 without evidence of having a COVID-19 test completed. The facility identified a COVID-19 outbreak in the facility on 11/2/20. During an interview on 11/17/20 at 3:20 PM, the Administrator stated the staff doing the employee testing are responsible to make sure everyone gets their weekly COVID-19 test. They keep a log of the employees and their weekly test results. At the end of each week the acting DON and administrator get a copy of the log sheets, so they know who is out of compliance for weekly testing and needs a test. When staff are out of compliance with weekly COVID-19 testing they cannot work until they are tested . The acting DON keeps track and lets the administrator know so they can get in touch with the agency to see if they have any test results for contract staff. During an interview on 11/17/20 at 3:22 PM, the acting DON stated she keeps track of weekly COVID-19 staff testing on tracking sheets that have facility and contract staff listed. The acting DON stated she has contacted the contract staff and the agency for any test results they may have, but does not have any other record of test results. They have no documentation of COVID-19 test results for LPN #1, CNA #2 and CNA #3, and the expectation is that staff get tested for COVID-19 weekly. They offer testing on Tuesdays and Fridays and staff should be getting their weekly test done. During an interview on 11/17/20 at 4:00 PM, the acting DON stated the facility is responsible to test contract staff for COVID-19 before they work if they haven't provided any test results to the facility. The acting DON stated it was her responsibility to make sure contract staff had COVID-19 results prior to working. If contract staff haven't been tested , they test them when they come in to work. The acting DON also stated they have staff who can perform testing on residents and staff at any time. 415.19(a)(1)

Plan of Correction: ApprovedDecember 15, 2020

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A Quality Assurance Performance Improvement meeting was held immediately following incident. Once the Statement of Deficiencies was received the facility convened it?s QAPI committee to examine the deficiencies cited. QAPI team (Consisting of the Administrator and Department Heads) completed an assessment of causative factors as well as a root cause analysis that may have contributed to the citation. The QAPI Team identified issues regarding frequency of staff testing for employees and contract employees with results during a facility outbreak. Interventions include education of all staff on weekly staff testing. Staff educated to report concerns with practices to supervisor. QAPI team will measure performance improvement or decline and evaluate effectiveness of corrective actions taken. LPN #1, CNA #2 and #3 have since been tested for COVID -19 symptoms and immediately in serviced on the proper protocol for testing every week for COVID-19. Corrective Action taken for other residents with the potential to be affected: An audit of all COVID-19 testing and results received has been completed regarding compliance of all employees with the proper protocol for testing every week for COVID-19. All staff educated No immediate concerns were identified and data was collected for trending non-compliance concerns. Systemic Measures to prevent recurrence: Policy review include: Policy review of [DIAGNOSES REDACTED] COVID-19 Testing guidelines effective 11/2020 has been reviewed and no revisions are necessary. All staff members will be in-serviced on policies and Guidance. The facility will review and implement monitoring system to self-identify issues or concerns with non-compliance with every staff member weekly testing. The DON/Administrator or designee will check the schedule daily for the next day to ensure who is coming in has been COVID tested and will maintain a log to track all staff, including agency to ensure all employees who have worked is tested during the required timeframe. If a staff member does not obtain COVID testing they will be removed from the schedule for the following week. All staff across all shifts will be educated on procedure. An audit tool has been created to ensure compliance of all staff being tested weekly according to payroll sheets. This audit will be conducted by the Administrator weekly ongoing. The facility will collect data from various sources related to high risk, high volume, and problem-prone issues and discuss at QAPI meetings. QAPI team will analyze the data collected to identify performance indicators signaling deviation from expected performance and to determine underlying causes and contributing factors. A QAPI action plan was developed and corrective actions were implemented such as staff education adherence to staff testing and tracking. Action plan included. Quality Assurance Monitoring: DON, Administrator or designee will conduct audits of all employee COVID-19 testing in conjunction with staffing sheets to ensure that all staff who work were tested . Follow up QAPI monthly to see progress and make sure compliance is met. The Director of Nursing will present all data on compliance with employee screening frequency compliance at the QAPI meeting until such time the team feels that there is 100% compliance. QAPI Team will monitor data related to the issue to determine if they are sustaining corrections, or if revisions are necessary Compliance date for P(NAME): 1/15/2021 ? Responsible person: DON, Administrator or designee

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §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. §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.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2020
Corrected date: January 15, 2021

Citation Details

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 11/17/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure staff were checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: Executive Order 202.11, dated (MONTH) 27, 2020, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS DOH DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated 5/11/20, documented This Directive supplements the prior DOH Advisory concerning hospital discharges to Nursing Homes (NHs). , as well as the DAL sent on (MONTH) 29, 2020. The directive documented With respect to COVID-19, state and federal rules and regulations require that NHs adhere to appropriate safety measures including, but not limited to: . Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The facility policy and procedure (P&P) titled Infection Control with a revision date of 4/2020 documented all health care personnel (HCP) will be screened for respiratory symptoms and temperatures before each shift. All HCP who are noted with or have reported symptoms and/or fever will be sent home and referred to their primary medical provider. The policy did not include screening staff every 12 hours while on duty. During an interview on 11/17/20 at 9:10 AM, the Administrator stated they received two positive resident results on 11/11/20 and the most recent staff COVID-19 positive result was received on 11/16/20. Review of staff schedules titled Nursing 4 Week Schedule dated 10/25/20 through 11/21/20 revealed: - Licensed Practical Nurse (LPN) #1 worked 16 hours on 11/4/20 on Unit A - LPN #2 worked 16 hours on 10/31/20, 11/6/20, and 11/9/20 on Units A and B. 11/2/20, 11/3/20, 11/10/20, 11/12/20, 11/13/20 and 11/16/20 on Unit B. - LPN #3 worked 16 hours on 11/1/20, 11/7/20, 11/8/20, 11/11/20, 11/14/20 and 11/15/20 on Unit A. During an interview on 11/17/20 at 10:05 AM, Licensed Practical Nurse (LPN) #2 stated the staff get screened daily at the front main entrance of the facility. He stated staff will only get rescreened and temperature retaken if they leave the property and come back to the facility. The LPN stated he works 16 hour shifts every week. During an interview on 11/17/20 at 11:45 AM, LPN #3 stated he works 16- hour (7 AM to 11 PM) shifts on the weekends and is off during weekdays unless he picks up extra time. He stated the last time he worked a 16-hour shift was 11/15/20. He stated he gets screened for any exposure to COVID-19 or potential signs/ symptoms including temperature check when he first comes in, at the start of his shift at 7:00 AM. LPN #3 further stated he doesn't get rescreened or temperature retaken at any point in time after coming in. Additionally, he stated he works on Unit A and is often the one who screens staff as they come in to work on the weekends. LPN #3 stated all staff get screened when they first arrive to the facility or if they leave the property and come back in. Review of COVID-19 Staff Screening Log REVISED sheets dated 10/31/20 through 11/16/20 revealed LPN #1, 2 & 3 were not screened every 12 hours while on duty on the respective dates they worked a 16-hour shift. During an interview on 11/17/20 at 11:40 AM, the Staffing Coordinator stated they have staff that work double shifts, which is 16 hours. Staff do not get rescreened when working a double shift because they are already in the building and they get screened when they come in for the start of their first shift. They don't rescreen after the first shift because if staff don't leave the property, they don't need to be rescreened. If staff leave the property to get food, they get rescreened. During an interview on 11/17/20 at 2:20 PM, the Administrator, in the presence of the acting DON/ IP, stated staff get screened and have temperature taken, prior to entering the building, at the start of their shift. If they leave the grounds they are supposed to be rescreened again. They use a sign in log for recording that staff were screened. After hours and off shifts, the Supervisor is responsible to make sure staff members are screened. The Unit A Nurse will complete the screening in the absence of the Supervisor. Corporate writes policies for all guidance that comes out. The expectation is that staff should be rescreened every 12 hours. The administrator stated there was no documentation that LPN's #1, 2 and 3 were rescreened every 12 hours on the days they worked 16 hours. 415.19 (a)(1) 400.2

Plan of Correction: ApprovedDecember 15, 2020

A Quality Assurance Performance Improvement meeting was held immediately following incident. Once the Statement of Deficiencies was received the facility convened it?s QAPI committee to examine the deficiencies cited. QAPI team (Consisting of the Administrator and Department Heads) completed an assessment of causative factors as well as a root cause analysis that may have contributed to the citation. The QAPI Team identified issues regarding frequency of staff screening for employees working a double shift (16 hours) Specifically the facility failed to require all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and at least every 12 hours while on duty. Areas reviewed include area for staff to report for testing every shift. Interventions include education of all staff on reporting for screening at the beginning of every shift including during a double shift. Staff educated to report concerns with practices to supervisor. QAPI team will measure performance improvement or decline and evaluate effectiveness of corrective actions taken. LPN #1, #2 and #3 have since been screened for COVID -19 symptoms and immediately in serviced on the proper protocol for screening every shift for respiratory symptoms and temperature checks. The screening log was revised to reflect, ?All staff working more than 12 hours must report to be rescreened during the first half of their second shift to the nursing supervisor or designee? Corrective Action taken for other residents with the potential to be affected: An audit of all employee log sheets has been completed regarding compliance of all employees with the proper protocol for screening every shift for respiratory symptoms and temperature checks. All staff educated. No immediate concerns were identified and data was collected for trending non-compliance concerns. Systemic Measures to prevent recurrence: Policy reviewed and revised include: Policy - Infection Control with a revision date of 4/2020 has been reviewed and revised to include COVID-19 symptoms checks at least every 12 hours while on duty. All staff members will be in-serviced on policies and guidance. The facility will review and implement monitoring system to self-identify issues or concerns with non-compliance with every shift respiratory symptom screening and temperature check. The facility will collect data from various sources related to high risk, high volume, and problem-prone issues and discuss at QAPI meetings. QAPI team will analyze the data collected to identify performance indicators signaling deviation from expected performance and to determine underlying causes and contributing factors. A QAPI action plan was developed and corrective actions were implemented such as staff education adherence to temperature checks and respiratory screening at the beginning of every shift and every 12 hours. Quality Assurance Monitoring: Nursing supervisor/manager will conduct audits of all employee screening in conjunction with staffing sheets every shift by to ensure all staff has been rescreened as applicable. The Administrator will conduct daily audits to ensure the compliance of staff screening and compare list to anyone who is working doubles x 4 weeks and monthly x 12 months. Follow up QAPI monthly to see progress and make sure compliance is met. The Director of Nursing will present all data on compliance with employee screening frequency compliance at the QAPI meeting until such time the team feels that there is 100% compliance. QAPI Team will monitor data related to the issue to determine if they are sustaining corrections, or if revisions are necessary Compliance date for P(NAME): 1/15/2021 ? Responsible person: Administrator or designee