Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) responsible for the infection prevention and control program (IPCP), as required by facility policy and federal regulations. Review of the facility's Infection Control Policy and Procedure indicated the need for one or more individuals to be designated as the IP, responsible for developing, implementing, and overseeing the IPCP, including surveillance and staff training. However, the facility's documentation for the designation of an IP was left blank, and the facility assessment only referenced a plan for one full-time IP/ADON without evidence of actual assignment or qualification. Interviews with facility leadership confirmed that there was no qualified IP in place. The DON, who started in the role recently, acknowledged lacking the required infection control certification and stated that the facility did not have an approved IP. The Administrator and the President of Clinical Operations both confirmed the absence of an IP, noting that a staff member who previously assisted with the role was no longer employed. No information was provided regarding any residents directly affected at the time of the deficiency.