Deficiencies in Infection Control Policy Review and Water Management Plan
Penalty
Summary
The facility failed to ensure an annual review of its Infection Control policy and procedures to verify adherence to current national standards of care. During the survey, documentation was requested to show that the Infection Prevention policy and program had been reviewed annually, but neither the Infection Preventionist nor the Director of Nursing could provide evidence of such a review. The policy provided did not indicate when it had been implemented or last reviewed, and no verification of an annual review was available by the time of survey exit. Additionally, the facility did not have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. The Environmental Services Director was unable to confirm when the last review of the Water Management Plan had occurred or identify the current members of the interdisciplinary water management team. The Water Management Policy on file was developed by previous owners and had not been updated to reflect the current ownership or reviewed for ongoing effectiveness.