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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2021
Corrected date: February 15, 2021
Citation Details Based on interview and record review during the COVID-19 Infection Control Focused Survey completed on 1/21/21 the facility did not 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 COVID-19. Specifically, for one (Certified Nursing Assistant (CNA) #2-a contract employee) of three employees reviewed for COVID-19 testing, the facility had no documented evidence of weekly COVID-19 test results. 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. The NYS DOH (New York State Department of Health) DAL (Dear Administrator Letter) NH 20-16, Testing and Visitation Requirements in Red, Orange and Yellow Zones, dated 11/10/2020 documented On (MONTH) 9, 2020, as part of the Cluster Action Initiative, Governor Cuomo issued EO 202.68 which established red, orange and yellow zones and imposed restrictions and limitations within those zones. On (MONTH) 10, 2020, EO 202.73 amended the nursing home testing requirements to require that nursing homes in red, orange or yellow zones test all personnel as directed by the Commissioner of Health. This DAL requires all nursing homes in red, orange or yellow zones to test or make arrangements to test all personnel twice a week. Review of the facility policy and procedure (P&P) titled COVID-19 Resident and Staff Testing dated 9/2/20 documented CMS requires that the facility test all residents and staff for COVID-19. Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility. The facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. Documentation of testing should include but not be limited to: Document the date(s) that testing was performed for all staff, and the results of each test. Review of a facility document titled Employee Weekly Testing Requirement-Update dated 11/12/20, documented the DOH notified all facilities that if they are located in an area designated as a COVID-19 cluster zone, all full time staff will be required to be tested twice per week; part time and per diem staff who work 3 days or less are only required to be tested on ce per week. It documented the facility was under a Yellow Zone Cluster. As a result, all staff must be tested during available lab days and times. Please be sure you continue to be tested twice weekly in order to be able to work at the facility. During an interview on 1/21/20 at 9:00 AM, the Director of Nursing (DON) stated, the most recent resident COVID-19 positive test result was received on 1/20/20 and six facility staff went out 1/20/21 with COVID-19 positive test results. In addition, the DON stated 13 staff were placed on quarantine last week due to COVID-19 positive test results. Review of the (Long Term Care) LTC Respiratory Surveillance Line List provided by the facility for COVID-19 positive residents revealed 29 residents tested positive for COVID-19 from 12/22/20 through 1/19/21. The facility was in a COVID-19 outbreak for the weeks of 12/22/20, 12/27/20, 1/3/21, and 1/10/21. Review of the COVID-19 Employee Line Listing provided by the facility for COVID-19 positive staff revealed 33 staff tested positive for COVID-19 from 12/25/20 through 1/15/21. The facility was in a COVID-19 outbreak for the weeks of 12/20/20, 12/27/20, 1/3/21, and 1/10/21. Review of facility employee testing records from 12/20/20 through 1/12/21 revealed that CNA #2 did not have COVID-19 test results for the weeks of 12/20/20, 12/27/20, and had only one documented test result for the week of 1/3/21 (on 1/6/21). Review of CNA #2 Time Cards (employee timesheets) dated 12/20/20 through 1/12/21 revealed: - CNA #2 worked in the facility on 12/19/20, 12/20/20, 12/22/20, 12/23/20, 12/28/20, 12/29/20, 12/30/20, 1/2/21, 1/3/21, 1/4/21, 1/5/21, 1/6/21, 1/7/21, 1/11/21, and 1/12/21. During an interview on 1/21/21 at 2:42 PM, the facility Administrator stated he gave the surveyor all the test results he had for CNA #2 and he had no other laboratory results or documentation of test results. During a telephone interview on 1/21/21 at 4:35 PM, CNA #2 stated that she worked in the facility three to five days per week and was aware of the requirement to get tested two times per week if working in the facility more than 3 days a week. CNA #2 stated she worked over night shifts and afternoon shifts and sometimes the testers were there from 3:00 PM to 5:00 PM. CNA stated, she didn't remember why she didn't get tested . During an interview on 1/21/21 at 3:25 PM, the agency Supervising Director stated their agency supplied staff to the facility and that the facility provided the COVID-19 testing. The agency Supervising Director stated it was the responsibility for agency staff to get COVID-19 testing completed through the facility. During an interview on 1/21/21 at 3:20 PM, the DON stated, it was the responsibility of Human Resources (HR) and the facility Administrator to track the staff that work in the facility get tested to remain in compliance with weekly COVID-19 testing. She stated they had no additional documentation of CNA #2's COVID-19 testing. During an interview on 1/21/21 at 3:40 PM, the Director of HR stated if staff worked more than three days per week, they were required to have for COVID-19 testing completed two times per week. She stated she and the facility Administrator tracked COVID-19 testing for all employees that work in the facility. She stated testing was offered in the facility four days per week in the morning and afternoon to allow all shifts the opportunity to get tested . The HR Director stated CNA #2 worked for an agency and it was the facility's responsibility to ensure agency staff members complete COVID-19 testing and remain in compliance. She stated she was not aware CNA #2 had only one COVID-19 test result from 12/19/20 through 1/12/21. They may have just missed her somehow. During an interview on 1/21/21 at 3:50 PM, the facility Administrator stated he and HR are responsible for tracking staff COVID-19 testing and to make sure they are in compliance. The Administrator stated they educated staff when the testing requirement increased from one time per week to two times per week if staff work 4 or more days in the facility. The Administrator stated, agency staff were educated just like everyone else. They are on their tracking roster, and they accommodate staff by having the laboratory at the facility four times per week to do testing. The Administrator stated he did not recognize that CNA #2 had missed her COVID-19 testing and he did not know why. 415.19 (a)(1l); 400.2 | Plan of Correction: ApprovedFebruary 12, 2021 Immediate Corrective Action Administrator, upon being made aware that CNA#2 had missed several required weekly Covid-19 tests for the weeks of 12/20/20, 12/27/20, and 1/3/21 requested the Human Resources Director contact CNA #2 to inquire why the tests were missed. Employee stated she didn?t think she missed those tests but did not recall the reasoning as to why she did. Administrator had Human Resources notify both the employee and her agency that she was terminated effective immediately. Administrator had the Human Resources Director conduct a staff testing re-audit for the previous weeks of 1/8/21 and 1/15/21 to determine if any additional employees were found to be out of compliance with the weekly testing requirement. No other non-compliance issues were noted to have occurred. Identification of Residents Facility respectfully states that residents had the potential to have been affected by this deficient practice. Systemic Changes Administrator and Human Resources Director determined that the tracking will be handled by the individual department heads for their respective staff to ensure compliance of their staff weekly testing compliance. Effective 2/8/21 each department head will receive from Human Resources each week a roster for their department?s employees. All department heads will be responsible for tracking and ensuring weekly Covid-19 testing compliance. Any staff found to be out of compliance by their respective department head will be promptly removed from the schedule and progressive discipline will be initiated Each week the department heads will return their rosters to Human Resources who will audit those rosters to ensure the staff testing compliance has been met. Administrator will be promptly notified of any instances of non-compliance and the remedy implemented. Quality Assurance Monitoring Frequent weekly tracking of staff compliance by the department heads with respect to Covid-19 testing compliance will clearly determine overall staff compliance. Employees found to be out of compliance will be removed from the schedule for the remainder of the week and subject to disciplinary action. Human Resources Director will receive the tracking rosters back from the department heads each week to verify testing compliance. Human Resources Director will complete weekly audits for 3 months and quarterly for 3 months to ensure compliance is maintained. The QAPI committee will meet monthly to review overall compliance with the revised system that has been implemented and will make recommendations for changes to the system if necessary. Any negative findings will be reported to the Administrator immediately. Correction Date & Responsible Person The correction date for F886 is (MONTH) 15, 2021. The Administrator is responsible for this correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2021
Corrected date: February 15, 2021
Citation Details Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 1/21/21, 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 that one of three employees (Certified Nurse Aide (CNA) #1) reviewed were screened 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: Review of a NYS DOH Directive titled Hospital Discharges and Admissions to Nursing Homes and Adult Care Facilities, dated 5/11/20, documented This Directive supplements . the DAL (Dear Administrator Letter) sent on (MONTH) 29, 2020. The Directive further 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. Review of a CMS (Centers for Medicare and Medicaid Services) memorandum (QSO 20-14-NH) updated 9/28/20 documented facilities should screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, or sore throat. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. Review of the facility Policy and Procedure (P&P) titled COVID-19 Health Screening Check revised 4/14/20 documented the facility will conduct required COVID-19 screening checks for anyone entering the facility during COVID-19 outbreaks. All individuals being screened will be required to complete a COVID-19 questionnaire to obtain information related to active signs and symptoms of illness, recent international travel and infection control practices. All employees, agency staff and HCP (health care providers) will be required to have their temperature taken on each shift and no less than every 12 hours. Review of the (Long Term Care) LTC Respiratory Surveillance Line List provided by the facility for COVID-19 positive residents revealed 29 residents tested positive for COVID-19 from 12/22/20 through 1/19/21. Review of the COVID-19 Employee Line Listing provided by the facility for COVID-19 positive staff revealed 33 staff tested positive for COVID-19 from 12/25/20 through 1/15/21. During an interview on 1/21/21 at 9:00 AM, the Director of Nursing (DON) stated, the most recent resident COVID-19 positive test result was received on 12/20/20 and six COVID-19 positive staff went out yesterday (1/20/21). In addition, the DON stated 13 staff were placed on quarantine last week due to COVID-19 positive test results. Review of CNA #1 Timecards (employee timesheets) dated 12/20/20 through 1/21/21 revealed: - CNA #1 worked more than 12 hours shifts on 12/21/20, 12/22/20, 12/31/20, 1/6/21, 1/7/21, 1/13/21, 1/14/21, and 1/20/21. Review of facility Covid Screening Forms dated 12/21/20, 12/22/20, 12/31/20, 1/6/21, 1/7/21, 1/13/21, 1/14/21, and 1/20/21 revealed CNA #1 was not screened every 12 hours while on duty. During an interview on 1/21/21 at 9:41 AM, CNA #1, stated they worked double shifts (16 hours) twice weekly. They get screened for COVID-19 upon entering the building at 7:00 AM and temperatures were documented on the COVID-19 screening form provided by the facility once daily. CNA #1 stated they were unaware they had to be rescreened after working twelve hours. Nobody told them they needed to be rescreened. During an interview on 1/21/21 at 3:41 PM, the ADON/IP stated, she was familiar with the NYSDOH guidance regarding screening staff every 12 hours while on duty. The ADON/IP stated staff are expected to rescreen and re-temp after 12 hours, preferably prior to starting their next scheduled shift in case staff developed COVID -19 symptoms throughout the day. Some staff documented their temperature for their rescreen on the COVID -19 screening form from the morning. Staff were expected to fill out new COVID -19 screening forms. During an interview on 1/21/21 at 3:45 PM, the Director of Nursing (DON) stated, she was familiar with the guidance on screening staff every 12 hours while on duty. The DON stated the Administrative Assistant/Receptionist verified and initialed completed COVID -19 screening forms. The forms were scanned daily into the computer, documented on the computer log, and sent to the Administrator. The Administrator was responsible to monitor for staff compliance. The DON further stated staff were expected to re-screen after 12 hours. During an interview on 1/21/21 at 3:50 PM, the Administrative Assistant/Receptionist stated she verified and signed the screening forms. The forms get scanned into the computer and the files were forwarded to the Administrator. COVID -19 screening forms were documented into a logbook located at the reception desk and the forms were kept in a box behind the reception desk. The Administrative Assistant/Receptionist further stated she did not monitor staff hours and she was not aware of the re-screening process. During an interview on 1/21/21 at 3:54 PM, the Administrator stated, he and the Administrative Assistant/Receptionist were responsible for monitoring staff screening. Staff were screened, answered the COVID -19 screening questionnaires and temperatures were checked prior to the start of each shift. The Administrative Assistant/ Receptionist was responsible to collect the form and initial it once the information was verified and was accurate. The Administrator stated the COVID -19 Screening Forms were placed into a binder or into a box after they were scanned into the computer and sent to him. The Administrator further stated there was no documentation that CNA# 1 had been re-screened between shifts. Staff were expected to return to the reception area, re-screen, and re-temp prior to the start of their next scheduled shift or at the end of 12 hours. 415.19(a)(1); 400.2 | Plan of Correction: ApprovedFebruary 12, 2021 Immediate Corrective Action Administrator, upon being made aware of the re-screening non-compliance by CNA #1, requested the DON to review signatures from the in-services provided to all staff regarding the re-screening requirement to determine if CNA#1 had signatures on the attendance sheets. On 12/8/20 and on 1/7/21, CNA#1 had signatures on both of the attendance sheets for the most recent in-services which included the re-screening requirement under infection control. DON gave CNA#1 an educational counseling on 1/21/21 and re-in-serviced CNA#1 on 1/21/21 with respect to the re-screening requirement and facility policy in which all staff must be re-screened in the lobby every time the employee is scheduled to work more than 12 hours, or is scheduled for a double shift, in which they should re-screen prior to the start of that second shift. Identification of Residents Facility respectfully states that residents had the potential to have been affected by this deficient incident. Systemic Changes All staff were re-in-serviced on 1/25/21 regarding the re-screening requirement. It was made clear that the expectation is that any staff that works more than 12 hours or is scheduled to work a double shift, should be re-screened in the lobby prior to the start of their second shift. This includes a temperature check and completion of the screening form. The employee will place a copy of their re-screen form either in the staffing coordinators mailbox or give to the Nursing Supervisor who will in turn put in the staffing coordinators mailbox for auditing and compliance purposes. A mailbox is located on the 1st floor in both buildings. A voice message was sent by the Administrator to all staff reminding them of the re-screening requirement on (MONTH) 7, 2021. A memo was distributed to all staff with payroll on (MONTH) 12, 2021 reiterating the re-screening requirement, the expectation that a copy of the second screen will be put in the staffing coordinators mailbox, and the potential for progressive disciplinary action for non-compliance. Signs were posted in both lobbies reminding staff of the re-screening requirement. All Department Heads, Nursing Unit Managers, and Nursing Supervisors have been instructed to remind their respective staff who are working doubles to be re-screened before the second shift begins and verify that the second screen was completed. The Nursing Supervisors are responsible for enforcement of this requirement. Quality Assurance Monitoring Staffing coordinator will audit those staff that worked doubles the prior business day to ensure compliance. Any staff member found to be out of compliance will be subject to progressive disciplinary action. Staffing coordinator will complete weekly audits for 3 months and quarterly for 3 months to ensure compliance is maintained. The QAPI committee will meet monthly to review overall compliance with the current system that has been implemented. The QAPI committee will make recommendations for changes to the system if necessary. Administrator will be provided a weekly update on staff compliance and/or non-compliance and the remedy for such non-compliance. Any negative findings will be reported to the Administrator immediately. Correction Date & Responsible Person The correction date for F880 is (MONTH) 15, 2021. The Administrator is responsible for this correction Directed Plan Of Correction/Root Cause Analysis The Administrator is responsible for the correction of this deficiency. Jodie Collins, RN MSN LNHA is an Independent Consultant that has been retained by the facility for required compliance with the Directed Plan of Correction for F880. A. A complete assessment of the causative factors was completed at the QAPI meeting held on (MONTH) 10, 2021 The following issues were identified that contributed to the issues identified for the deficiency: ? The employee failed to follow facility policy and procedure based on Department of Health guidance regarding the rescreening requirements for staff working 12 hours or more as well as staff working double shifts. This employee, as have all staff, has been in-serviced on numerous occasions regarding this requirement. B. Identify the specific steps/interactions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase. ? The employee was re-in-serviced on 1/21/21 regarding the regulation which requires all staff to be checked for Covid-19 symptoms, including temperature checks upon the start of each shift and every 12 hours or before their second shift if doing a double shift while on duty. ? All staff were re-in-serviced on 1/25/21 on the re-screening requirement and it was made clear that the expectation is that any staff scheduled to do a double shift should be re-screened in the lobby prior to the start of the second shift. This includes a temperature check and completion of the screening form. ? A voice message was sent by the Administrator to all staff reminding them of the re-screening requirement on (MONTH) 7, 2021. ? A memo was distributed to all staff with payroll on (MONTH) 12, 2021 reiterating the re-screening requirement and the risk of disciplinary action for non-compliance. ? Signs were posted in both lobbies at the temperature stations reminding staff of the re-screening requirement. ? All Department Heads, Nursing Unit Managers, and Nursing Supervisors have been instructed to remind their respective staff who are working doubles to be re-screened before the second shift begins. All managers and supervisors will be instructed to verify that the re-screening has occurred for any employees doing double shifts and the copies of the screening form has been put in the staffing coordinators mailbox. C. Identify the routine triggers or parameters the facility will implement for the above deficiencies, which will signal or alert staff of an evolving problem or defiant practice situation. Indicate how this system will be carried out by the facility: ? Any staff working a double must make a copy of their re-screen form, the original to be submitted to the receptionist and the second copy to be put in the staffing coordinators? mailbox. ? The staffing coordinator, on the next business day, will verify that any employees that worked a double on the previous day did complete a re-screen form. Any employee found to be out of compliance will be subject to progressive disciplinary action. D. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance: ? Staffing coordinator will verify that the employees who have worked doubles are in compliance with facility policy and procedures and department of health regulations. Staffing coordinator will complete weekly audits of staff who have worked double shifts to ensure each employee has a corresponding re-screen for those shifts. ? The QAPI committee will meet monthly to review overall compliance with the current system that has been implemented. ? The QAPI committee will make recommendations for changes to the system if necessary. ? Administrator will be provided regular updates on staff compliance or non-compliance and the remedy for such non-compliance. ? Any negative findings will be reported to the Administrator immediately. |