Other·January 11, 2024

§42 CFR §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. (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: (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. (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. 22 CCR § 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, handwashing facility, soap dispenser and individual towels. (b) The facility shall adopt, observe, and implement written infection control policies and procedures. 22 CCR §72523- Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (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 12/05/2023 the California Department of Public Health (CDPH) received a Complaint indicating COVID19-Noncompliance in the facility. On 12/07/23, the CDPH conducted an unannounced visit at the facility to investigate the allegation. The facility failed to: 1. Report the facility’s COVID-19 positive cases to the Department of Public Health Licensing and Certification (CDPH). 2. Implement its policy and procedure (P&P) titled "Infection Prevention and Control Program", which indicated outbreak management was a process of preventing the spread of infection to other residents and reporting the information to appropriate public health authorities. 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 3's admission record indicated Resident 1, was a 39- year-old male, admitted to the facility on 11/2/23 with diagnosis of Hypertension, Enterotoxigenic Escheria Coli Infection (bacterial diarrheal illness), Hyponatremia (electrolyte abnormality) and Bacteremia (the presence of bacteria in the bloodstream). A review of Resident 3’s "COVID-19 Point of Care (POC) Test Result", dated 12/23/23, indicated Resident 3 was positive for COVID-19. On 12/7/2023 at 10:00 a.m., during an observation, the facility's highlighted floor map was noted to have 3 (three) COVID positive rooms and 2 (two) rooms that residents were exposed to close contacts upon entrance. On 12/7/2023 at 12:04 p.m., during an interview and record review, with the Infection Prevention Nurse (IPN), the All Facilities Letter 23-08 ([AFL] a letter from the Center for Health Care Quality [CHCQ], Licensing and Certification [L&C] Program to health facilities that are licensed or certified by L&C) was reviewed. The IPN stated the COVID outbreak was reported to the Research Electronic Data Capture ([Redcap] an application that provides facilities a platform to report COVID-19 data and other information to DPH) and to the National Healthcare Safety Network ([NHSN] a national healthcare-associated infection reporting system developed and maintained by the Centers for Disease Control and Prevention (CDC) on 12/4/2023 after testing the first COVID positive resident. The IPN stated, "I did not know I had to report to the local District Office." On 12/7/2023 at 12:30 p.m., during an interview and record review, with the Director of Nursing (DON), the AFL 23-08 was reviewed. The DON stated the AFL letters were used for guidance. The DON stated the letter indicated to report COVID-19 cases to the local District Office. The DON stated, "We did not know about this." A review of the facility's Policy and Procedure (P&P) titled, "Infection Prevention and Control Program," dated October 2018, indicated outbreak management was a process of reporting COVID-19 information to appropriate public health authorities. The facility failed to: 1. Report the facility’s COVID-19 positive cases to the CDPH. 2. Implement its P &P "Infection Prevention and Control Program", which indicated outbreak management was a process to prevent the spread of infection to other residents and reporting the information to appropriate public health authorities. 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. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.