Failure to Ensure Qualified Infection Preventionist and Adequate Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the infection prevention and control program, as required by CMS regulations. After the previous IP left unexpectedly, the facility assigned IP duties to IP-C and the DON, but neither had completed the required specialized training in infection prevention and control. IP-C had started the CDC IP training modules but had only completed 10 out of 24 modules, while the DON had not begun any IP training. The newly hired IP had just started training and was not yet qualified. The facility also lacked an infection prevention and control policy that described the IP's training requirements or specified the number of hours needed for the IP role. Surveyor interviews and record reviews revealed that, during this period, there were multiple instances where staff returned to work before meeting CDC recommendations following COVID-19 or gastrointestinal illness. Additionally, the facility assessment did not specify the required hours for the IP position, and there were gaps in the infection prevention process due to the absence of a trained IP. The facility did not have a trained IP available to train the new IP, further contributing to deficiencies in the infection prevention and control program.