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F0882
F

Lack of Credentialed Infection Preventionist

Palmyra, Pennsylvania Survey Completed on 01-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be non-compliant with the requirement to have a credentialed Infection Preventionist (IP) as part of their Infection Prevention and Control Program (IPCP). According to the facility's policy titled 'Infection Control,' which was 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 January 25, 2025, the Administrator admitted that the facility did not have any staff members who were credentialed as infection preventionists. This deficiency was previously cited on July 18, 2024, and December 17, 2024, indicating a recurring issue with compliance in this area.

Plan Of Correction

1. A full-time Infection Preventionist has been hired and will be working with both Kadima at Campbelltown and Palmyra. She is an RN and has the required certification for the position of IP. 2. The company will also hire a second nurse to complete the Infection Preventionist course so that there will always be a backup ensuring the problem does not recur. 3. The DON or designee will monitor Infection Control credentials as well as any issues weekly for 4 weeks and then monthly for 2 months to ensure compliance compliance.

See complete original report
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