Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection preventionist (IP) who had completed specialized training in infection prevention and control, as required by facility policy. The policy specified that the infection preventionist is responsible for coordinating, implementing, and updating the infection prevention and control program (IPCP), as well as providing education and training on evidence-based practices. The policy also required the IP to be employed onsite and at least part-time. However, during the survey, it was found that the facility did not have a designated person in charge of the IPCP, and the role was being temporarily filled by the regional clinical resource (RCR) and the minimum data set coordinator (MDSC), neither of whom had the required infection control certification. Interviews with the MDSC, NHA, and RCR confirmed that there was no designated or certified infection preventionist overseeing the IPCP at the time of the survey. The MDSC stated she did not oversee the IPCP and did not have the required certification, while the RCR, who was temporarily filling in, also lacked the necessary certification. The NHA acknowledged that the facility did not have a designated person in charge of the IPCP, and the RCR was only filling in until the position could be filled. This failure had the potential to affect all residents residing in the facility at the time of the survey.