Health inspection·December 21, 2023

42 CFR §483.80 The facility must establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. (a) The facility must establish an infection prevent and control program that must include, at a minimum, the following elements: (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. (a) (2) Written standards, policies, and procedures for the program which must include, but are not limited to: (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. 22CCR § 72321. Nursing Service -Patients with Infectious Diseases. (a) Patients with infectious diseases shall not be admitted to or cared for in the facility unless the following requirements are met: (1) A patient suspected of or diagnosed as having an infectious or reportable communicable disease or being in a carrier state who the attending officer determines is a potential danger, shall be accommodated in a room, vented to the outside, and provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. 22 CCR § 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (3) Infection control policies and procedures. 22 CCR § 72541- Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or Department may require. Every fire or explosion which occurs in or the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 11/6/2023, the California Department of Public Health (CDPH) received a complaint indicating three positive residents’ cases of coronavirus (COVID-19, a highly contagious respiratory infection caused by a virus that could easily spread from person to person) which met the COVID-19 outbreak (a sudden rise in the incidence of a disease) criteria. On 11/8/2023, the CDPH conducted an unannounced visit at the facility to investigate the COVID-19 outbreak. The facility failed to: 1. Implement its policy and procedure titled, “Infection Prevention and Control Program” which indicated to report outbreak information to the appropriate public health authorities. 2. Report the facility’s COVID-19 outbreak to the Licensing and Certification District Office per “All Facilities Letter 23-09” ([AFL] a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that contained changes in requirements in healthcare, enforcement, or general information that affects the health facility) dated 1/18/2023. As a result, there was a high risk for an increase in COVID-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. A review of Resident 1’s Admission Record indicated Resident 1 was a 77 year old male, admitted to the facility on 4/22/2023 and readmitted on 9/27/2023 with diagnoses including urinary tract infection ([UTI] harmful bacteria enters the kidneys or bladder which could cause pain, fever and blood in the urine), and diabetes (disease that result in too much sugar in the blood). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care planning tool) dated 8/28/2023 indicated Resident 1 had severely impaired cognitive (thought process) skills for daily decision making and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for Activities of Daily Living (ADL’s) including bed mobility (how resident moved while in bed), transfer, dressing, eating, toilet use and personal hygiene). During an interview on 11/8/2023 at 10:30 a.m., the Assistant Director of Nursing (ADON), stated the COVID -19 outbreak started on 11/4/23 with Resident 1, who had symptoms of coughing and fever. The ADON stated the facility had a total of 13 residents positive with COVID-19. During an interview on 11/8/2023 at 4:32 p.m., the Administrator (ADM), the ADM stated the COVID-19 outbreak was reported to the local Department of Public Health and was not sure if the outbreak was reported to the District Office (CDPH). During an interview on 11/12/2023 at 10:46 a.m. the Infection Prevention Nurse (IP), stated the COVID-19 outbreak was reported to the local Department of Public Health and was not aware of the need for the facility to report to the CDPH, and therefore, it was not done. A review of the facility’s P&P titled, “Infection Prevention and Control Program” dated 6/2021, indicated an infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P also indicated outbreak management was a process that consisted of determining the presence of an outbreak, preventing the spread to other residents, and reporting the information to the appropriate public health authorities. A review of the AFL 23-09, from the California Department of Public Health, dated 1/18/2023, the AFL reminded the licensed health facilities of requirements to report outbreaks and unusual infectious disease occurrences to their local health department and Licensing and Certification District Office and provides investigation and reporting thresholds for reporting for COVID-19. The facility failed to: 1. Implement its policy and procedure titled, “Infection Prevention and Control Program” which indicated to report the information to the appropriate public health authorities. 2. Report the facility’s COVID-19 outbreak to the Licensing and Certification District Office per AFL 23-09 dated 1/18/2023. As a result, there was a high risk for an increase in COVID-19 cases in the facility, and placed residents, staff, and the community at risk for contracting the COVID-19 virus. This violation had a direct or immediate relationship to the health, safety, security of residents.