Non-compliance with Act 52 Infection Control Plan
Penalty
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The current infection prevention and control policy, last reviewed in December 2024, was found to be lacking in several areas. The policy is intended to prevent, identify, control, and reduce the risk of infections among employees, volunteers, visitors, and contract healthcare workers. However, it did not include all the necessary components as mandated by Act 52, such as a multidisciplinary committee involving various staff members and community representatives, effective measures for detecting and controlling healthcare-associated infections, and protocols for handling MRSA and MDRO exposures. During the survey, it was confirmed by the infection preventionist that the facility's infection control policy did not meet all the requirements of Act 52. Additionally, there was no evidence of infections being reported to the state reporting agency since May 2024, which is a requirement under Act 52. This lack of compliance indicates a significant gap in the facility's infection control measures, potentially affecting the health and safety of residents and healthcare workers.
Plan Of Correction
PA-PSRS is now current. To identify residents with the potential to be affected, DON/designee will complete an audit of the last 30 days of the requirements of ACT52 to ensure requirements are met. To prevent re-occurrence, DON/designee will educate ADON/IP on requirements of ACT52. To monitor and maintain compliance, DON/designee will audit submission of data to PA-PSRS monthly x 4 to ensure requirements are met. All results will be brought to the QAPI committee.