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Based on observation, interview and record review, the facility failed to ensure infection control measures were implemented and enforced to protect againts acquisition of infection in 1 of 1 construction area observed.

Findings include:

Observation on 8/29/23 at 10:30 AM at the entrance to construction project on 2 nd floor showed a document in plastic sheet protector labeled "Infection Control Checklist-During/ and Post Construction for South Tower Elevator Lobby.
Dates that the checklist were documented as being competed were: 8/3/23, 8/7/23, 8/10/23, 8/11/23, 8/14/23, 8/15/23, 8/17/23, 8/21/23 and 8/24/23. The checklist was the only document in the plastic sheet protector.

Interview with the Director of Infection Prevention (ID# 56) at the time of observation, she stated that the infection Control Risk Assessment (ICRA) should also be placed in the sheet protector at the entrance of the construction area.

Interview with the Director of Facilities (ID# 55) on 8/29/23 at 11:45 am, stated that the checklist are to have someone assigned to check daily.

Record review of facility policy titled " Construction, Renovation, and Maintenance Policy" dated 8/1/23 showed the following information:

PURPOSE:
During periods of construction or maintenance that may compromise the level of infection prevention in the facility, Infection Control Risk Assessment (ICRA) measures will be implemented to protect all patients, healthcare workers and/or visitors from the acquisition of an infection related to the construction.

Planning Phase
8. A copy of the approved PCRA shall be maintained at in a facility designated location. The ICRA section of the PCRA will be posted at the job site for review.

9. Environmental Monitoring
a. The Infection Prevention Department will plan for the environmental monitoring, as appropriate, for the project in conjunction with the Safety Officer or safety designee.
b. All environmental monitoring will be approved by the infection Prevention and Safety Officer or designee.

Compliance Monitoring
1. the contractor's designee, the Infection Control personnel, Safety Officer and the facility construction project manager will conduct compliance monitoring as necessary.
2. Construction sites will be monitored for compliance 7 day a week, regardless if the construction area is active. Compliance will be recorded on the Daily Fire and Life Safety, Infection Prevention, and Safety and Security Compliance checklist.
3. The Director of Facility Management, Director of Construction, Safety Officer and Infection Prevention Manager shall delegate the operational day-to-day responsibility for administering and enforcement of the infection prevention policies and procedures.