Failure to Employ Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was employed at least part time each month from late December 2024 to mid-May 2025. Payroll records confirmed that the previous IP's last day was 12/26/2024, and the next IP did not begin until 05/12/2025. During interviews, the Human Resource Manager verified that no other individual worked as an IP during this period. Although the CEO stated that two other employees held IP certification, it was confirmed that neither performed the duties of the IP, including oversight of the Antibiotic Stewardship Program, immunization, staff and resident education, or infection control surveillance. The interim Director of Nursing also confirmed that there was no IP in place during this time frame, resulting in a lack of oversight for the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program. The absence of an IP was identified through document review and staff interviews, and the deficiency was cross-referenced with F881.