Lack of Credentialed Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with infection control regulations due to the absence of a credentialed Infection Preventionist (IP). According to the facility's policy on infection control, last reviewed on August 21, 2023, staff members are required to report all infections to the IP, who is responsible for conducting routine surveillance. However, during an interview on December 17, 2024, the Administrator admitted that the facility did not have a staff member who was a credentialed IP. This deficiency was previously cited on July 18, 2024, indicating a recurring issue with compliance to CFR 483.80 (b) and relevant state codes regarding resident care policies and nursing services.
Plan Of Correction
1. The Director of Nursing is completing the Infection Preventionist Program and will act as the interim IP until another RN is hired and completes the IP program. 2. The facility is applying for at least one other full-time employed RN to complete the infection preventionist program. 3. The Director of Nursing was re-educated on the Infection Preventionist requirements. The NHA will ensure at least two facility staff members are credentialed at all times. 4. The NHA or designee will conduct a one-time audit of each Infection Preventionist's credentials to ensure they meet the monitoring criteria. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.