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Based on record review and staff interview, the facility failed to ensure the infection preventionist/infection control professional developed and implemented hospital-wide infection prevention and control policies and procedures that adhered to nationally recognized guidelines to limit the spread of COVID 19 (A0772).

Based on record review and staff interview, the facility failed to ensure the infection preventionist/infection control professional developed and implemented hospital-wide infection prevention and control policies and procedures that adhered to nationally recognized guidelines to limit the spread of COVID 19 for two staff with community exposure (Staff N and Staff O). This had the potential to affect all patients receiving services from the facility. The facility had 105 active patients at the time of the survey.

Findings include:

Review of the Centers for Disease Control (CDC) Clinical Questions about COVID-19: Questions and Answers (Updated 03/04/21) revealed if HCP (Healthcare Personnel) are living with someone who has been diagnosed with SARS-CoV-2 infection, should they be excluded from work? If so, for how long? The answer was Yes. HCP who have any kind of exposure for which home quarantine is recommended should be excluded from work. If HCP are able to quarantine away from the infected individual living with them, they should quarantine at home and not come into work for 14 days following their last exposure to the infected individual. If HCP are not able to quarantine away from the infected individual living with them and have ongoing unprotected exposure throughout the duration of the individual's illness, they should remain in home quarantine and be excluded from work until 14 days after the infected individual meets criteria for discontinuation of home isolation. If HCP develop SARS-CoV-2 infection while they are in quarantine, they should be excluded from work until they meet all return to work criteria for HCP with SARS-CoV-2 infection. Home quarantine and work exclusion of asymptomatic exposed HCP who have recovered from SARS-CoV-2 infection in the prior 3 months might not be necessary.

Review of the CDC's Guidance for Asymptomatic HCP Who Were Exposed to Individuals with Confirmed SARS-CoV-2 Infection (Updated 03/11/21) revealed higher-risk exposures generally involve exposure of HCP's eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if these HCP were present in the room for an aerosol-generating procedure. Following a higher-risk exposure, work restriction of asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 3 months and asymptomatic HCP who are fully vaccinated HCP is not necessary. HCP who have traveled should continue to follow CDC travel recommendations and requirements, including restriction from work, when recommended for any traveler. HCP with community exposures should be restricted from work if they have a community exposure for which quarantine is recommended.

Further review revealed this guidance applies to HCP with potential exposure in a healthcare setting to patients, visitors, or other HCP with confirmed SARS-CoV-2 infection. Exposures can also occur after prolonged close contact with someone with suspected SARS-CoV-2 infection when testing has not yet occurred or if results are pending. Work restrictions described in this guidance might be applied to HCP exposed to such an individual if test results for the individual are not expected to return within 48 to 72 hours. Therefore, a record of HCP exposed to individuals with suspected SARS-CoV-2 infection should be maintained. If test results will be delayed more than 72 hours or the patient is positive for SARS-CoV-2 infection, then the work restrictions described in this document should be applied.

HCP with travel or community exposures should inform their occupational health program for guidance on need for work restrictions. HCP who have traveled should continue to follow CDC travel recommendations and requirements, including restriction from work, when recommended for any traveler. HCP with community exposures should be restricted from work if they have a community exposure for which quarantine is recommended.

Work restriction of asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 3 months and asymptomatic HCP who are fully vaccinated HCP is not necessary.

Updates to this guidance as of 12/14/2020 included a link to the Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2, which provides guidance on testing potentially exposed healthcare personnel. Clarify that, in general, healthcare personnel with travel or community-associated exposures where quarantine is recommended should be excluded from work for 14 days after their last exposure.

The CDC's Crisis Capacity Strategies to Mitigate Staffing Shortages was reviewed. It stated when staffing shortages are occurring, healthcare facilities and employers (in collaboration with human resources and occupational health services) may need to implement crisis capacity strategies to continue to provide patient care. When there are no longer enough staff to provide safe patient care, implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing. Allow asymptomatic HCP who are not fully vaccinated and have had a higher-risk exposure (defined in Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to SARS-CoV-2) to SARS-CoV-2 but are not known to be infected to continue to work onsite throughout their 14-day post-exposure period. If permitted to work, these HCP should be monitored for symptoms as described above. If shortages continue despite other mitigation strategies, as a last resort consider allowing HCP with suspected or confirmed SARS-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work.

Review of the facility's pandemic Preparedness policy (EC.EM.30, Revised March 2020) revealed under Management of asymptomatic healthcare personnel exposed to pandemic pathogens: 1. Personnel who may have been exposed to pandemic pathogen should be vigilant on the signs and symptoms pertinent to the specific pathogen. Persons who develop the specific signs and symptoms should limit interactions outside the home and should not go to work, school, childcare, church, or other public areas. 2. Exposed unprotected healthcare personnel who are asymptomatic must be evaluated prior to work each day by completing the "Employee Pathogen-like Illness Screening Log". Ensure coverage is inclusive of students, contract, and hospital employees. 3. Exposed unprotected healthcare personnel should monitor their own temperature twice per day and report any elevated temperature (i.e.,>38 degrees C) by following their department's report-off protocol.

The facility's Employee Infection Control Log was reviewed. The log revealed two employees, Staff N and Staff O, had community exposure to family members who were positive with SARS-CoV-2 on 04/05/21. The log stated both Staff N and Staff O were not vaccinated and not tested. Both Staff N and Staff O were instructed to continue to work and self monitor for symptoms.

The facility's Employee Infection Control Log revealed multiple other staff members (approximately 40 employees) who had community exposure to SARS-CoV-2 were instructed to work and self monitor since 11/18/2020.

Staff M was interviewed on 04/14/21 at 3:05 PM. Staff M reported the facility began having a staffing crisis in December 2020. Staff M reported staff with community exposure to SARS-CoV-2 were permitted to work and self-monitor.

On 04/14/21 at 4:43 PM, Staff A sent an email stating the facility began vaccinating staff on 12/23/2020 on behalf of the health department. Staff A reported on 12/29/2020, the facility officially started vaccinating as a facility.

Staff P was interviewed on 04/15/21 at 11:07 AM. Staff P reported the facility was following the CDC's Strategies to Mitigate Healthcare Personnel Staffing Shortages when the facility allowed community-exposed staff to continue to work during their quarantine period.

The Director of Nursing from the Local Health Department was interviewed on 04/15/21 at 1:39 PM. She stated that a health care worker who was exposed in the community (at home, close contact) needed to quarantine. She confirmed there was a difference between healthcare related exposures and community related exposures.

The facility's 2021 Infection Prevention and Control Plan (Revision 9.0) was reviewed. The plan stated for Mitigation of Risks Contributing to Healthcare Associated Infections - Other hospital healthcare-associated infection risk mitigation measures: Adherence to nationally recognized infection prevention and control precautions, such as current CDC guidelines and recommendations, for infections/communicable diseases identified as present in the organization based on the following:
- The potential for transmission
- The mechanism of transmission
- The care, treatment, and service setting
- The emergence or reemergence of pathogens in the community that could affect the organization.

The facility's Covid-19 Employee Health policy (HR.EH.29, Date of Origin December 2020, Reviewed April 2021) was reviewed. The stated purpose was intended to assist with assessment of risk and application of work restrictions for Healthcare Personnel (HCP) who are diagnosed positive with COVID-19, experiencing COVID-19-like symptoms, or potential exposure in the community or at work. Separate guidance is available for travel and community related exposures. The CDC has also released guidance about return to work criteria for HCP with COVID-19 and strategies for mitigating HCP staffing shortages. The stated goal was to, A) protect the HCP because of their often extensive and close contact with vulnerable individuals in healthcare settings. This policy is based on guidance from the CDC recommendations. Occupational Health should use clinical judgement as well as the principles outlined in the CDC to assign risk and determine the need for work restrictions. B) To establish a process for resumption of contact tracing and application of work restrictions that can be considered. C) To ensure continuity of operations of essential functions. The stated procedure was: A) The operational definition of "prolonged" refers to cumulative time period of 15 or more minutes during a 24-hour period. Close contact is defined as within 6 feet of the confirmed COVID-19 person or unprotected direct contact with their infectious secretions. For purposes of this policy, any duration should be considered prolonged if the exposure occurs during performance of an aerosol generating procedure. B) This policy applies to HCP with potential exposure in community and/or healthcare setting to patients, visitors, or other HCP with confirmed COVID-19. Exposures can also occur from suspected case of COVID-19 or from a person under investigation (PUI) when testing has not yet occurred or if results are pending.

This deficiency substantiates Substantial Allegation OH00118852