Failure to Report Tuberculosis Case to State Health Department
Summary
The facility failed to report a case of tuberculosis (TB) to the Pennsylvania Department of Health (DOH) through the state Event Reporting System, as required by regulation. This deficiency was identified during a review of clinical files, facility documentation, and staff interviews. The Director of Nursing confirmed that a resident had tested positive for TB, and while the facility collaborated with the local county to report the case and implement recommended measures, they did not notify the DOH state survey agency. The Nursing Home Administrator also confirmed this failure to report the TB infection as required by the regulation.
Plan Of Correction
1. Employee E2 submitted reportable to Department of Health. 2. Facility will review incident reports and any new infection diagnosis for past 30 days to identify any missed reportable. 3. Director of Nursing will be re-educated on event reporting requirements. 4. The DON/designee will complete random audit to ensure all reportable events have been submitted to DOH reportable system weekly for four weeks and monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.
Penalty
The facility failed to report new COVID-19 cases in accordance with national standards. Despite an outbreak beginning in late December, the facility's COVID line listing was not updated to include residents testing positive in late January. An RN confirmed new cases on multiple floors, and the Regional VP admitted to not realizing the need for continuous reporting.
The facility did not report cases of Influenza A to the appropriate health agencies for 13 residents who tested positive. The infection control documentation showed positive tests over several weeks, and staff confirmed that the required notifications were not made.
Failure to Report Communicable Diseases
Penalty
Summary
The facility failed to maintain a system for reporting communicable diseases, specifically COVID-19, for residents in accordance with accepted national standards. This deficiency was identified through a review of the facility's policy on 'Transmission-Based Isolation Precautions,' which was last reviewed on January 7, 2025. The policy indicates that the facility is responsible for taking appropriate precautions to prevent the transmission of pathogens. However, the facility's COVID line listing showed an outbreak beginning on December 27, 2024, with the last resident testing positive on January 23, 2025. The listing was not updated to include residents who tested positive on January 27 and January 28, 2025. During an observation and interview on January 28, 2025, a Registered Nurse (RN) was seen distributing N95 masks and placing PPE in hallways, indicating the presence of COVID-19 cases on multiple floors. The RN confirmed a resident had tested positive on the 3rd floor that day. Additionally, the Regional Vice President of Operations admitted that the facility failed to report new cases of COVID-19 after the initial two cases were reported on December 27, 2024. The Vice President acknowledged a lack of awareness regarding the need for continuous reporting of additional cases, leading to the facility's failure to report new COVID-19 cases.
Plan Of Correction
1. New cases of reportable diseases (covid) were reported to DOH via ERS system. Line listing for covid and all diseases/infections updated and tracked by facility IP/DON. 2. The NHA will be educated by VP of Operations or designee on reportable diseases to Pa DOH event reporting system. 3. An audit of reportable diseases will be completed weekly x 3 weeks then monthly x 2 months. 4. Results of audits submitted to facility QA process.
Failure to Report Influenza A Cases
Penalty
Summary
The facility failed to report cases of Influenza A to the appropriate health agencies and the Division of Nursing Care Facilities field office for 13 residents who tested positive. The infection control documentation revealed that residents tested positive for Influenza A on various dates from December 27, 2024, to January 18, 2025. An interview with the facility's Infection Control Practitioner and the Director of Nursing confirmed that the mandated state agencies were not notified of these positive cases, indicating a lapse in the facility's reporting protocol for reportable diseases.
Plan Of Correction
Preparation and/or constitution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. The Administrator corrected the deficiency by reporting the influenza cases to the DOH on 12/27/24 at 0800, Event Number: 1066952. The Infection Control Nurse, Director of Nursing, Administrator, and Assistant Administrator reviewed and were educated on the PA regulations regarding ERS reporting requirements. § 27.21a. Reporting of cases by health care practitioners and health care facilities. (2) Influenza is reportable within 5 working days after being identified by symptoms, appearance, or diagnosis. Examination of the prior 24-hour clinical report and the daily Interdisciplinary Clinical Team Meeting will discuss any residents who exhibit signs of influenza, e.g., fever, chills, cough, sore throat, rhinorrhea, muscle/body aches, headaches, fatigue, vomiting, or diarrhea, and the need for diagnostic testing. If diagnosis is confirmed, treatment, isolation, and state reporting within 5 working days will be completed. Facility follows the Infection Control Guidance set for by the Centers for Disease Control and Prevention. The Infection Control Nurse has created a log of any reportable diseases, infections, and conditions. An additional checkbox will be added to the Infection Preventionist's Infection Control Log to indicate any reportable diseases have been or need to be submitted to the Department of Health. Infection Control and Nursing Administration reviewed all cases; there were no additional reportable events required. The Infection Preventionist will report monthly x three months to QAPI to ensure regulatory compliance in reporting infectious diseases has been met. The Infection Preventionist's log will be reviewed by QAPI team and the Administrator to ensure reporting requirements have been met.
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