Elderwood at Amherst
October 8, 2020 Covid19 Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 8, 2020
Corrected date: December 4, 2020

Citation Details

Based on interview, and record review conducted during the COVID-19 Infection Control Focus Survey completed on 10/8/20, 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 (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated 4/29/20, documented As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must 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 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 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 Preventing the spread of COVID-19 dated 9/4/2020 documented it is the policy of our company to comply with Center for Disease Control (CDC) and State Department of Health (DOH) guidelines regarding awareness and prevention of the spread of Coronavirus 2019 (COVID-19). Preventing the introduction of respiratory germs into the facility will include screening of individuals entering the facility (employees, contract staff, medical staff, operators, volunteers, vendors, etc.). Everyone will be screened prior to entry into the facility. Screening will include assessment of travel history, exposure history, fever and respiratory symptoms (cough, shortness of breath, or sore throat) and a temperature assessment. The policy did not include re-screening of employees every 12 hours while on duty. During an interview on 10/8/20 at 8:45 AM, Registered Nurse (RN) #2 stated that facility census was 51 residents including two COVID-19 positive residents on Unit Three. During an interview on 10/8/20 at 9:35 AM, Certified Nurse Aide (CNA) #2 stated she has worked overtime and double shifts. She stated employees get screened when they enter the facility at the start of their shift and do not get re-screened or have temperature re-taken when working a double shift (which are two 8-hour shifts, totaling 16 hours). During an interview on 10/08/20 at 2:13 PM, CNA #1 stated she has worked double shifts and worked one the previous night. The facility does not rescreen her after working 12 hours and this is the first she heard of the requirement. During an interview on 10/8/20 at 2:16 PM, RN #1 stated she works two 16- hour shifts and one eight -hour shift per week. She stated she doesn't get re-screened or have her temperature re-checked when working a 16-hour shift because she does not leave the building. RN #1 further stated she doesn't get re-screened if she stays in the building the whole shift and was never told she had to do that. During an interview on 10/8/20 at 2:00 PM, the Director of Nursing (DON) stated she was unsure but would have to check on the process for how often staff are screened for signs or symptoms of COVID-19 and have temperatures taken when working a double shift or over 12 hours. During an interview on 10/8/20 at 2:10 PM, the Regional Consultant RN Infection Preventionist (IP), in the presence of the DON, stated they do not log temperatures or re-screen staff when they work a double shift and it is not logged anywhere. They stated there was no additional documentation of screening of staff or temperature re-checks when staff work a double shift or overtime. During an interview on 10/8/20 at 2:55 PM, the Regional Consultant RN IP and DON stated they were not aware of the NYS DOH Directive 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. They stated they were going to review the directive so the requirement could be implemented. 415.19(a)(1) 400.2

Plan of Correction: ApprovedOctober 30, 2020

Title F tag 880 (SS = D) CFR(s): 483.80(a)(1)(2) _(4)(e)(f): Infection Prevention and Control The following actions were accomplished for the residents identified: All staff working 12 or more hours were immediately re-screened for symptoms of COVID-19 by the Director of Nursing. Staff education on the procedure for staff screening of COVID-19 symptoms when working 12 or more hours in accordance with NYS DOH Directive was immediately initiated by the Director of Nursing. A process for re-screening of staff working 12 or more hours for COVID-19 symptoms was immediately implemented by Director of Nursing. The following corrective actions will be implemented to identify other residents that may be affected by the same practices: All residents have the ability to be affected by this deficient practice. The policy and procedure for employee screening of COVID-19 symptoms was immediately reviewed by the Chief Nursing Officer in conjunction with the QA committee on 10/08/2020. The policy was updated in accordance with regulation on 10/16/2020 which states ?Elderwood facility staff will be re-screened every twelve hours while on duty?. The Chief Nursing Officer in conjunction with the QA Committee updated the screening tool by adding the ?time? the COVID-19 Screening Checklist was conducted to ensure all staff working 12 or more hours were re-screened including having their temperature re-taken. The following system changes will be implemented to assure continuing compliance with regulations: To ensure that the practice does not reoccur, the Director of Nursing in conjunction with the Nursing Management Team will provide educational training to all staff consisting of but not limited to: 1. Facility policy relating to Preventing the Spread of COVID-19. 2. Facility procedures relating to the COVID-19 Re-screening process for all staff working 12 hours or more daily. 3. Full facility In-Service education relating to preventing the spread of COVID-19 and procedures for re-screening when working 12 or more hours. Department Managers/Supervisors and/or assigned designee will review their daily schedules and utilize the COVID-19 Screening Checklist by filling out the name section of the Screening Checklist for all staff working 12 hours or more and placing it in the COVID-19 Screening Checklist Binder to ensure that the Supervisor and/or assigned designee ensure that all staff working 12 hours or more daily are re-screened including having there temperature re-taken. Development of a weekly compliance audit will be designed to ensure the COVID-19 Screening Checklist is being completed to confirm all staff working 12 hours or more are re-screened for COVID-19 symptoms. The facility?s compliance will be monitored utilizing the following quality assurance system: The Director of Nursing and/or assigned designee will conduct at most 5 audits per week for one month, then conduct 5 audits monthly for two months to ensure staff are being re-screened when working 12 hours or more in the facility. Any deficient practices will be reported to the Administrator immediately. The Director of Nursing will review audits and report findings to the Quality Assurance Performance Improvement (QAPI) monthly for three months and report statistical compliance review at the next Quarterly Quality Assurance meeting. Recommendations for the changes in process will be provided and implemented as needed. Primary Responsible Individual(s): Director of Nursing and Department Managers/Supervisors Work Team: Administrator, Director of Nursing, Regional Clinical Consultant, QAPI/PIP team