Non-compliance with Act 52 Infection Control Requirements
Penalty
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The deficiency was identified through a review of the facility's infection prevention and control policy, which was last reviewed in October 2024. The policy was intended to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infections. However, it was found that the facility's infection control policy and procedures did not include all the necessary requirements mandated by Act 52. Specifically, the facility did not establish a multidisciplinary committee with representatives from various groups, as required by the Act, to oversee the infection control plan. During an interview, the Infection Preventionist confirmed that the facility's infection control policy did not meet the requirements of Act 52. It was revealed that infections were reported to the state agency at the end of each month, rather than within the required 24-hour timeframe. This reporting method was based on the Infection Preventionist's previous practice at another facility, which did not align with the current regulatory requirements. No evidence was provided during the survey to confirm the facility's compliance with Act 52, leading to the identification of this deficiency.
Plan Of Correction
1. The Infection Preventionist is now reporting any HAI (Healthcare Associated Infections) to the PA-PSRS system within 24 hours of confirmation. 2. Education provided to the Infection Preventionist on reporting requirements on HAI's to the PA-PSRS system. 3. The DON/designee will audit the HAI's submission timeframe weekly for four weeks and monthly for two months. 4. Results of the audits will be submitted to the QA Committee for three months.