Failure to Annually Review and Implement Infection Control Policy
Penalty
No penalty information released
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 failed to develop and implement an infection prevention and control program, including conducting an annual review of its infection control policy. During an interview, an administrative nurse confirmed that the infection control policy had not been reviewed since 11/22/2020, and there was no evidence of an annual review as required. The facility's policy stated that it would maintain an infection prevention and control program following national standards, but this was not upheld. Additionally, the administrative nurse indicated expectations for staff to properly remove PPE to prevent cross-contamination, but the lack of policy review suggests this may not have been adequately addressed.