Failure to Report Health Care-Associated Infections
Penalty
Summary
The facility failed to comply with the requirements of the Act 52 Infection Control Plan, specifically regarding the reporting of health care-associated infections. According to the review of ACT 52 of 2007, Chapter 4, section $1303.404, nursing homes are required to electronically report health care-associated infection data to the department and the authority using nationally recognized standards based on CDC definitions. Additionally, section §1303.405 mandates that the occurrence of a health care-associated infection in a health care facility be deemed a serious event, requiring written notification to be documented. However, the facility was unable to provide documented evidence of reporting these infections to the Pennsylvania Patient Safety Reporting System (PA-PSRS) or of sending written notifications to residents or their responsible parties from October 2024 through January 2025. The deficiency was further highlighted during an interview with the facility's Infection Preventionist (IP) on February 11, 2025. The IP, who had been in the role since October 23, 2024, admitted to not reporting infections to PA-PSRS from the time she assumed her position until the end of January 2025. She stated that she was unaware of the requirement to report health care-associated infections to PA-PSRS until recently, indicating a lack of awareness and training regarding the facility's obligations under the Act 52 Infection Control Plan.
Plan Of Correction
Data previously collected for October 2024 through January 2025 will be retroactively entered to be captured into the Pennsylvania Patient Safety Reporting System (PA-PSRS). Residents with facility health care-associated infections reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS) as per the Act 52 Infection Control Plan have the potential to be affected. Education provided to the Infection Control Nurse by the Director of Nursing on the process for reporting health care-associated infections to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Monitoring will be captured through auditing The Act 52 Infection Control Plan Pennsylvania Patient Safety Reporting System (PA-PSRS). Audits on PA-PSRS will be performed monthly for 3 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.