Failure to Report COVID-19 Outbreak and Enforce Staff Exclusion Requirements
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow an effective infection prevention and control program for residents and staff during a COVID-19 outbreak. The Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit requires that respiratory virus outbreaks be reported within 24 hours, defines an outbreak as either one confirmed case plus one symptomatic resident or two confirmed cases, and directs facilities to implement daily active surveillance using a case line list. The facility’s own infection control policy, updated 12/20/25, required HCP with fever or COVID-19–consistent symptoms to immediately notify a supervisor and be restricted from work until at least three days had passed from symptom onset or positive test and 24 hours without fever, with masking for at least seven days after onset. A facility-provided list showed that seven residents tested positive for COVID-19 over a series of dates, meeting the state’s outbreak definition, but review of information submitted to the Department of Health showed the facility failed to report the COVID-19 outbreak that began when two residents were confirmed positive within 72 hours. The facility also failed to maintain a line list documenting positive test dates, symptoms, and length of precautions for residents and staff, contrary to the outbreak checklist requirement for daily active surveillance. Staffing records showed that one RN (Employee E1) tested positive for COVID-19 and returned to work on the second day after the positive test, and another RN (Employee E2) tested positive and returned to work on the third day, both earlier than permitted under the Pennsylvania Department of Health guideline, which required at least three days from symptom onset or positive test and 24 hours afebrile before returning to work, with the earliest return on day four. In interviews, the DON confirmed that the facility did not maintain a line list, did not report the COVID-19 outbreak beginning when multiple residents became positive, and allowed the two RNs to return to work before the guideline-specified return-to-work dates, resulting in a failure to ensure an environment free from the potential spread of infection for seven residents and two employees.
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