HospitalInspections.org

Based on policy review, document review, and staff interview, the facility failed to establish a system to identify and prevent transmission of infections and communicable diseases for 5 of 5 sampled volunteers (Volunteers C, D, E, F and G). Administrative staff reported the facility had 20 volunteers at the time of the revisit.

Failure to identify infections and communicable diseases among volunteers as part of the infection control surveillance program could potentially result in transmission of communicable to patients and staff at the facility.

Findings include:

1. Review of the facility policy titled "Volunteer Credentialing", dated 6/5/13, revealed, in part, ". . . the following items must be completed prior to commencement . . . Medical Information Release Form. . . ."

2. Review of the credentialing files for Volunteers C, D, E, F, and G revealed a completed document in each file titled "Review of Medical Information Release Form for Volunteers". The document showed that the volunteer's healthcare providers completed the form for the volunteer based on the volunteer's health status. Both the volunteer and the healthcare provider signed and dated the completed document.

The completed Medical Information Release Forms for Volunteers in the credentialing files for Volunteers C, D, E, F, and G, lacked reference to information regarding health screening for infections and communicable diseases, any history of infections or communicable disease, or any increased health risk of acquiring infections applicable to the volunteer that the facility should be aware of prior to assigning the volunteer to work at the facility.

3. During an interview on 7/2/13 at 12:30 PM, Staff A, Health Information Management, acknowledged the volunteers do not receive a health screening for infections and communicable diseases prior to volunteering at the facility. Staff A acknowledged the Medical Information Release Form for Volunteers lacked documentation of any health screening for infections and communicable diseases.

During an interview on 7/2/13 at 12:40 PM, Staff B, Employee Health, acknowledged the volunteers do not receive a health screening for infections and communicable diseases prior to volunteering at the facility. Staff A acknowledged the Medical Information Release Form for Volunteers lacked documentation of any health screening for infections and communicable diseases.