HospitalInspections.org

Based on the Hospital document titled Workforce Member Confidentiality, hospital policy, review of Personnel records and staff interviews, the hospital failed to demonstrate Competency-based training and education of hospital staff in the Environmental Services department on the practical applications of infection prevention, and control guidelines, policies, and procedures for 3 of 8 employees interviewed (EVS staff #2, 3 and 7).

The findings included:

Review of the Hospital document titled, Workforce Member Confidentiality and Security Agreement revealed employees signed an agreement which included a Code of Conduct. The agreement informed the employee of the requirement to safeguard and protect passwords when necessary to perform job related duties. Employee signature was obtained prior to the start of employment to confirm the agreement with the requirement.

Review of the Hospital Policy Title: Infection Prevention and Control Plan review/revision date: January 2022 revealed, "...PURPOSE The purpose of the Infection Control Plan is to reduce risks of endemic and epidemic nosocomial infections in patients, health care workers and visitors ...INFECTION PREVENTION POLICIES AND PROCEDURES... *Written policies are made known to personnel performing patient care procedures that are associated with the potential for infection. Each director is responsible for training and educating their staff to pertinent Infection Prevention policies and procedures in collaboration with the Infection Prevention Specialist ...Preventing the Transmission of Infectious Diseases The appropriate screening for exposure and/or immunity to infectious diseases will be made available to all staff, including LIPs (Licensed Independent Practitioners), who come in contact with infections at the workplace. Staff including LIPs that have been, or are suspected of having an infectious disease that puts others at risk, will be provided or referred to assessment and potential testing, prophylaxis/treatment, or counseling services ..."

Interview on 07/12/2022 at 1400 revealed Hospital Administrative staff (Chief Executive Officer [CEO], Ethics, Compliance and Privacy Officer, Divisional Director of Risk and Claims Investigator and Division Director of Accreditation Officer) self-disclosed the identification of Environmental Services (EVS) staff with unreliable confirmation of completion of training and education. Interview revealed the EVS Supervisor had completed the computer education for several staff. Interview revealed the hospital administrative staff became aware that since it was questionable which staff may have completed their own computer education, the entire department would be reassigned the task of required computer education. Interview revealed all EVS staff were immediately reassigned training and education pertinent to Infection Control, Safety Risks, Radiation Safety Awareness, and Equity of Care. Interview revealed the staff were to begin the education immediately with 07/31/2022 as the expected completion date. Interview revealed, "...We were able to validate that [Named Supervisor] did have passwords and she admitted that she had done some trainings for the staff ..." Interview revealed the EVS Supervisor and Manager were "...no longer employed at the hospital as a result of the breech of Code of Conduct ..." Interview revealed a lack of oversight to ensure education was completed by the assigned staff member. Interview revealed during the initial investigation in February 2022, the Facility CEO, Regional Director of EVS department, and EVS department first shift and second shift Supervisors were released of employment at the hospital. Interview revealed the new CEO started 07/02/2022, there was an Interim EVS Department Manager since May 2022 to current, a new EVS Manager with a start date of 07/18/2022, and a new EVS evening shift Lead employee for guidance with a date of hire on 06/27/2022. Interview revealed the Hospital Administrative staff had developed a plan for all EVS staff to complete the computerized training and education by 07/31/2022 to assure infection control and prevention practices.

Review of Personnel records for EVS staff revealed all staff of the department had yet to complete (as of 07/14/2022), the "Rapid Regulations" computerized education which would include infection control required topics. Review revealed the training was available, with a 07/28/2022 date of required completion.

Interview on 07/13/2022 at 1415 with EVS staff #2 revealed, the EVS Supervisor had knowledge of employee passwords to emails. Interview revealed, "... [Named Supervisor] would know our passwords and do the [Named Computerized] education ..." Interview revealed EVS staff #2 acknowledged the Supervisor and/or Manager had completed the computerized education for EVS #2.

Interview on 07/13/2022 at 1445 with EVS staff #3 revealed, the Supervisor and/or Manager had completed the computerized employee education for EVS #3.

Interview on 07/13/2022 at 1645 with EVS staff #7 revealed, the Supervisor and/or Manager had completed the computerized employee education for EVS #7.