Health inspection·January 6, 2023

CA Health & Safety Code § 1255.9 (a) (1) A skilled nursing facility shall have a full-time, dedicated Infection Preventionist (IP). (2) The IP role may be filled either by one full-time IP staff member or by two staff members sharing the IP responsibilities, as long as the total time dedicated to the IP role equals at least the time of one full-time staff member. (3) The IP shall be a registered nurse or licensed vocational nurse and shall not be included in the calculation of three and one-half hours of direct patient care per day provided to skilled nursing facility residents. (b) A skilled nursing facility shall have a plan in place for infection prevention quality control. (c) A skilled nursing facility shall ensure all health care personnel receive infection prevention and control training on an annual basis. F882 §483.80(b) Infection preventionist. The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The IP must: §483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; §483.80(b)(2) Be qualified by education, training, experience or certification; §483.80(b)(3) Work at least part-time at the facility; and §483.80(b)(4) Have completed specialized training in infection prevention and control. On 12/6/2022 at 9:42 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to conduct a recertification survey. During the recertification survey, CDPH determined the facility failed to: 1. Designate a full time and certified Infection Preventionist (IP – professionals who make sure healthcare workers and patients are doing are doing all the things to prevent infections) to perform an oversight of the Infection Prevention Control Program (IPCP – a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases) of the facility’s Infection Prevention Control program. 2. Ensure all dedicated IPs of the facility received specialized training (advanced training received in an accredited program that is beyond the basic education) and certifications (a formal attestation that the person meets the requirement) to conduct the role of an IP. 3. Implement All Facilities Letter 21-51 [AFL – letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L & C) Program to all health facilities that are licensed or certified by L & C] that required skilled nursing facility to have a dedicated full time and certified IP. These violations had the potential for the facility not to mitigate infectious diseases (illnesses caused by germs such as bacteria, viruses, and fungi that enter the body, multiply, and can cause an infection) through an effective infection prevention and control program in the facility. A review of the Employee Separation Report/Exit Interview dated 7/6/2022, indicated the facility’s IP resigned on 3/4/2022. During an entrance conference on 12/6/2022 at 9:42 am, the Administrator (ADM) stated the facility did not have an IP since February 2022. During an interview on 12/7/2022 at 1:57 pm, the Director of Nursing (DON) stated the facility’s IP team included the DON, the Clinical Nurse Manager (CNM), the facility’s in-house Pharmacist and the Infection Control Consultant (ICC). The DON stated the CNM is responsible for the day-to-day operation of the skilled nursing facility. The DON stated she was responsible for everything related to Coronavirus-19 (COVID-19 disease, a severe respiratory illness caused by virus and spread from person to person). The DON stated the Pharmacist was responsible for the vaccination of the employees, patients and the antibiotic stewardship (antibiotic use protocols that utilize an infection assessment tool, monitoring of antibiotic use, feedback, and education to prescribing providers). The DON stated the ICC was on-call (able to be contacted to provide professional service if necessary) 24 hours, 7 days a week to give guidelines related to infection control of the facility. During an interview on 12/7/2022 at 2:28 pm, the DON stated the facility needed a full time IP to keep track and educate facility’s staff of the updated and new regulations related to infection control. During an interview on 12/8/2022 at 12:22 pm, the DON stated both the DON and the CNM did not have the training and certifications on infection control. The DON stated it was important to have a full time IP in the facility to oversee staff and provide updates on infection control to help prevent the spread of infections for the safety of the residents and staff. A review of the facility’s policy and procedure, titled “Infection Prevention and Control,” with a revision date of 5/2022, indicated the Infection Control Coordinator had the direct responsibility for the infection control activities such as surveillance, control, reporting and prevention of infections throughout the facility. A review of the facility’s Mitigation Plan for Covid-19, with a revision date of 12/7/2022, indicated the facility would reassign a nurse on infection control duties on a full-time basis and would be trained and under the supervision of the infection control doctor. The policy indicated a full-time infection control nurse would also focus a significant portion of time to auditing infection control practices and just-in-time training of healthcare workers. A review of the AFL 21-51 sent to all skilled nursing facilities, dated 12/13/2021, with an effective date of 1/1/2022, indicated the AB 1585 expanded existing eligibility and minimum qualifications for a SNF’s IP. The IP must have primary professional training as a licensed nurse, medical technologist, microbiologist, epidemiologist, public health professional, or other health care related field. The IP must be qualified by education, training, clinical or health experience, or certification, and must have completed specialized training in infection prevention and control. Skilled nursing Facilities (SNFs) continue to be required to employ a full-time, dedicated IP. The facility failed to: 1. Designate a full time and certified Infection Preventionist to perform an oversight of the Infection Prevention Control Program of the facility’s Infection Prevention Control program. 2. Ensure all dedicated IPs of the facility received specialized training and certifications to conduct the role of an IP. 3. Implement AFL that required skilled nursing facility to have a dedicated full time and certified IP. These violations had the potential for the facility not to mitigate infectious diseases through an effective infection prevention and control program in the facility. The above violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of all the Patients in the facility.