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Based on observation and staff interview, the facility failed to ensure the facility's hospital-wide infection surveillance, prevention, and control policies and procedures adhered to nationally recognized guidelines in regard to COVID-19. This had the potential to afffect all patients receiving services from the facility. The census was 441 patients.

Findings include:

Review of the Centers for Disease Control and Prevention Infection Control Guidance dated 11/04/2020 revealed "symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented." "Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control."

On 11/16/2020 at 1:20 PM, upon arrival to the offsite therapy location at 4229 Pearl Road, Cleveland and entrance to the facility from the parking garage, this surveyor was asked the reason for the visit but was not asked any screening questions and no temperature was taken. Staff D stated that screening was discontinued two or three weeks ago. Observations were made in the lobby until 2:10 PM with no screening observed. During these observations, Staff C stated that screening was discontinued three weeks ago. Signs were posted for visitation, mask requirements, and social distancing. During tour of the offsite facility on 11/16/2020 from 3:05 PM to 3:47 PM, the street level entrance was observed to have people entering with no screening observed. A staff member was posted near the entrance to ensure limited visitors were admitted to the facility, everyone wore masks, and to handout masks and face shields to staff. Signs were posted for visitation, mask requirements, and social distancing.

On arrival at the main facility entrance on 11/17/2020 at 8:00 AM, Staff E asked the reason for the surveyor's visit. Staff E stated screening was no longer done. Multiple people were observed entering the facility without being screened. Everyone was observed to be wearing masks. Signs were posted for visitation, mask requirements, and social distancing.

On 11/17/2020 from 1:00 PM to 2:30 PM; Staff F, Staff G, and Staff H were interviewed by video conference. They stated that on 11/12/2020 the facility stopped screening everyone entering the facility at all locations. The infection control team and executive leadership felt that they were not catching everyone if they were looking for only a few symptoms. They felt everyone should be viewed as having Covid and measures were already in place to protect patients and staff.

On 11/17/2020 from 3:00 PM to 4:15 PM, a tour of the facility was conducted. The main entrance, staff entrance and emergency room entrances were observed. All entrances were observed to have signs posted for visitation, mask requirements, and social distancing. No one was observed to screen anyone on entrance.

This deficiency substantiates Substantial Allegation OH00116988.