Failure to Designate Qualified Infection Preventionist Onsite
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing programs and activities to prevent and control infections from mid-October 2024 to February 21, 2025. According to the Centers for Medicare and Medicaid Services regulation §483.80(b)(3), the infection preventionist (IP) must work at least part-time at the facility and cannot be an off-site consultant. During this period, the facility did not have a designated IP who met these requirements, as confirmed by the Nursing Home Administrator and Director of Nursing. An interview with Employee E18, who was assigned the role of IP, revealed that the position was combined with wound care sometime in January, and the previous nurse handed over the responsibilities to the Director of Nursing around mid-October. Employee E18's certificate date was February 21, 2025, indicating a gap in having a qualified IP onsite. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to have a qualified individual responsible for infection prevention and control during the specified period.
Plan Of Correction
1. Facility has since had a full time Infection Preventionist. 2. NHA will receive education from Vice President of Operations on requirements for Infection Preventionist. 3. DON/designee to audit Infection Preventionist implementing programs and activities to prevent and control infections weekly x 4 weeks, then monthly x 4 months. 4. Results to be submitted to QAPI for review and approval.