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Based on interview and record review, the hospital failed to have an effective governing body that is legally responsible for the conduct of the hospital when there was not an effective hospital-wide program for surveillance, prevention and actions taken to address the need to make safe and timely interventions related to COVID-19 (a serious respiratory virus infection responsible for the current worldwide pandemic) infections. The infection control program did not report COVID-19 positive staff and patients to the local health department in a timely manner thus negatively affecting nine staff members (RN 1, RN 2, RN 3, RT 1, RN 4, RT 2, RN 5, RN 6, and RN 7) and one patient (Pt 1). (Refer to A 750)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner for staff and patients.

Based on interview and record review, the hospital failed to have an effective hospital-wide program for surveillance, prevention and timely actions to address the need to make safe and timely actions related to COVID-19 (a serious novel viral respiratory illness which is the cause of a current worldwide pandemic) infections. Hospital A did not have an effective surveillance system to identify, contain, and prevent COVID-19 infections in patients and staff when RN 2 and RN 3 were diagnosed with COVID-19 on 9/3/20, and contact tracing (a tool that can help slow the spread of infectious diseases, such as COVID-19) and investigation were not done timely (within 24 hours) to identify risks of exposure and prevent further transmission of COVID-19. This affected nine staff members (RN 1, RN 2, RN 3, RT 1, RN 4, RT 2, RN 5, RN 6, and RN 7) and one patient (Pt1). The infection control program did not report COVID-19 positive staff and patients to the local health department in a timely manner to help prevent the spread of COVID-19 in their facility. (Refer to A 750)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner for patients and staff.

Based on interview and record review, Hospital A failed to employ methods for preventing and controlling transmission of airborne (transported by air) and droplet bacteria and viruses, when the hospital could not provide documentation confirming that contracted physicians were fit tested (the size needed for individual to provide a facial seal) for N-95 respirator masks (a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of air born particles) in accordance with infection control guidelines from the Center for Disease Control and Prevention (CDC - a Federal agency whose main goal is to protect public health and safety through prevention and control of spread of infectious diseases and other diseases).

This failure resulted in Hospital A not ensuring source control practices and protection were in place for COVID-19 (an infectious respiratory disease which causes cough, shortness of breath, fever, chills, muscle pain, sore throat, or a loss of taste or smell) which had the potential to place patients and staff at risk for contracting COVID-19 infection.

Findings:

During a concurrent interview and record review, on 10/9/20, at 9:10 a.m., with Manager of Medical Staff Services (MMSS) and Human Resources Business Partner (HRBP), the Medical Doctor's (MD) 1 personnel file, indicated a N-95 respirator fit testing was not done initially or annually. The HRBP stated that fit testing was not required for the contracted physician.

During an interview on 10/9/20, at 3:32 p.m., with Director of Infection Prevention (DOIP), the DOIP stated, contracted physicians were provided the option for N-95 respirator fit testing at Hospital A. The DOIP stated Physicians were sent a notice of this service, and were notified via e-mail that they must get fit tested if they (Physicians) wore a new N-95 respirator type different from what they previously wore and fitted for.

During an interview on 10/9/20, at 3:55 p.m., DOIP stated, Hospital A staff would not be able to care for a positive COVID-19 patient until they were fit tested for a N-95 mask to prevent transmission of infection.

During an interview on 10/14/20, at 4:46 p.m., with System Director of Quality (SDQ), the SDQ stated, Hospital A's contracted physicians were not required to be N-95 respirator fit tested but were highly recommended to do so. The SDQ stated if Hospital A did not do the N-95 respirator fit testing, then a record was not kept of it. The SDQ stated Hospital A did not have documentation that MD 1 had been fit tested for the N-95. The SDQ stated he could not provide a policy and procedure requiring contracted physicians to be N-95 respirator fit tested, but was currently in the development phase of one.

During a review of Center for Disease Control and Prevention and National Institute for Occupational Safety and Health (CDC NIOSH), Filtering out Confusion: Frequently Asked Questions, dated April 2018, the CDC NIOSH indicated, " ...Fit Testing ...In addition to fit testing upon initially selecting a model of respirator ...fit testing be conducted annually ..."

Based on interview and record review, the infection control program for Hospital A failed to have an effective surveillance system to identify, contain, and prevent COVID-19 (a serious novel viral respiratory illness which is the cause of a current worldwide pandemic) infections in all patients and staff when RN 2 and RN 3 were diagnosed with COVID-19 on 9/3/20, and contact tracing (a tool that can help slow the spread of infectious diseases, such as COVID-19) and investigation were not done timely (within 24 hours) to identify risks of exposure and prevent further transmission of COVID-19. The infection control program did not report COVID-19 positive staff and patients to the local health department in a timely manner.

These failures negatively affected nine staff members (RN 1, RN 2, RN 3, RT 1, RN 4, RT 2, RN 5, RN 6, and RN 7) and one patient (Pt 1), in which eight were identified as COVID-19 positive between 9/3/20 to 9/22/20, and delayed implementation of actions to reduce risk to other staff and patients. The delay to report to local public health further delayed expert guidance/education in assisting the hospital in identifying the source of transmission and therefore, delayed containment of COVID-19 infections.

Findings:

During an interview on 10/5/20, at 1:45 p.m., with the Assistant Chief Nursing Officer (ACNO), the ACNO stated this hospital [Hospital A] had a practice of not admitting COVID-19 positive patients. The ACNO stated Hospital A was one of a three-hospital corporation and COVID-19 patients were admitted in the other two hospitals. The ACNO stated the Hospital A did not have an Emergency Department where patients would be seen with possible COVID-19 symptoms. If a patient became positive during their admission the hospital had a practice of transferring the patients to the one of the two hospitals in the corporation. The ACNO stated the three-hospital corporation shared staff (Physicians, Nursing, Nursing Assistants, Infection Preventionists, Environmental Services, Food Services). The ACNO stated patients scheduled for surgery were required to get a COVID-19 test done a couple days before so that the results were known before admission.

During a concurrent interview and document review, on 10/6/20, at 2:41 p.m., with the Manager of Quality and Regulatory (MQR), the COVID-19 Positive Staff List for Hospital A (undated), was reviewed. The MQR stated that this list was from Employee Health Department and was the most current up to date list of COVID positive staff at Hospital A. The MQR confirmed that there were 28 staff members on the COVID positive staff list and the date for the first positive was on 4/5/20 and the last staff member tested positive on 9/29/20.

During an interview on 10/6/20, at 3:40 p.m., with the Infection Preventionist (IP) and the Director of Clinical Performance Improvement and Infection Prevention (DOIP) , the IP stated that she provided education on donning and doffing of personal protective equipment (PPE), N95 (mask used as a respirator to prevent infection), and increased education on hand hygiene. The IP stated that she is responsible for the education of staff, on the spot (real time) corrections and training, make sure staff and managers are up to date on the latest information on infections to include most current COVID infections, and auditing for staff compliance. The DOIP stated that this IP was not responsible for contact tracing; they have other infection preventionist that do the contact tracing.

During a concurrent interview and document review, on 10/6/20 at 3:50 p.m., with the DOIP, the COVID-19 Positive Staff List for Hospital A (undated), was reviewed, along with an Exposure List (undated) the DOIP provided. The DOIP confirmed that both lists provided different information; both lists have staff name, employee numbers, department worked, job title or role, date of birth, facility, Test Date, date symptoms began or onset, and Last day worked. The COVID-19 Positive Staff List included what laboratory the staff member was tested by, actual signs and symptoms, staff phone number, and date cleared to work. The Exposure List includes date logged, Exposure period, symptomatic, mask type, number of HCW (healthcare workers) exposed, number of patients exposed, and a comment section where exposure information is input. The DOIP confirmed that the lists were not the same and RN 7's last day worked was missing on the Exposure List and RN 7 was missing from the COVID-19 Positive Staff List. The DOIP confirmed seven staff members were traced back to Pt 1:
1. Registered Nurse (RN) 2: tested positive 9/3/20; symptomatic 9/1/20; last day worked 8/31/20
2. RN 3: tested positive 9/3/20; symptomatic 8/30/20; last day worked 8/28/20
3. Environmental Services Supervisor (EVS): tested positive 9/4/20; symptomatic 9/4/20; last day worked 9/4/20 (note an x was placed next to this staff members name by the DOIP to indicate he had exposure to Pt 1, on the second list (was provided because the per the DOIP the first list was missing the second page) she gave me his name was not highlighted)
4. Respiratory Therapist (RT) 1: tested positive 9/9/20; symptomatic 9/7/20; last day worked 9/7/20
5. RN 4: tested positive 9/9/20; symptomatic 9/7/20; last day worked 9/7/20
6. RT 2: tested positive 9/10/20; symptomatic 9/7/20; last day worked 9/8/20
7. RN 5: tested positive 9/14/20; symptomatic 9/7/20; last day worked 9/6/20
8. RN 6: tested 9/14/20; symptomatic 9/10/20; last day worked 9/10/20
Per the Exposure list, all these staff members tested were symptomatic. RN 7 did not have an "x" next to his name to indicate he had been exposed to Pt 1. RN 7 tested positive 9/10/20; symptomatic 9/8/20; last day worked MISSING (note: per form logged date was 9/11/20).

During a review of the Electronic Medical records (EMR) for Pt 1, the Physician History and Physical (H&P), dated 8/25/20, indicated Pt 1 was admitted for surgery " ...Plan: High risk coronary artery bypass graft [heart surgery] and Mv [mitral valve- heart valve] replacement surgery may require mechanical support [ventilator to help Pt 1 breathe] ..." The H&P indicated that Pt 1 was a smoker with "Diagnosis: acute chronic congestive heart failure [heart function is weak, not able to pump blood properly] low systolic ef [ejection fraction- a measure of how well the heart pumps] coronary artery disease [fatty deposits in the artery walls that narrow the arteries] moderate MR [mitral valve regurgitation- the Mv does not shut properly so it allows for fluid to regurgitate] ischemic and non-ischemic cardiomyopathy [weakened heart muscle] ..." Further review of EMR lab results titled, "COVID Virus PCR, Diagnostic for Symptomatic Patients," dated 9/5/20, indicated "COVID ... Detected [positive for COVID-19]!!" Per Pt 1's EMR she was admitted with a cough and had a cough throughout her stay. Per Pt 1's EMR she had lab tests prior to admit for surgery that included a "COVID Virus PCR, Screen for Asymptomatic Patients," on 8/22/20 that indicated "COVID ... Not Detected [negative for COVID-19]."

During an interview on 10/7/20, at 8:30 a.m., with RN 4, RN 4 stated he helped care for Pt 1 multiple times during her stay (8/28/20-9/5/20), Pt 1 was not able to wear a mask. RN 4 stated he wore his surgical mask, gloves, and eye protection when attending to Pt 1's needs and when she was placed on isolation, he then wore an N95 mask, isolation gown, eye protection and gloves. RN 4 stated, "I think it was 9/7/20 around lunch time I had a random bout of diarrhea, went back to work and got through the shift and came home. The next morning I had a headache ... by the afternoon I was getting more tired and fatigued than normal ... woke up next day with a headache and sore throat and I called employee health ... employee health had me come in on 9/9/20 and get tested, by 9/10/20 test results were positive." RN 4 stated that he does recall RN 3 working with a "bit of a cough then he was gone (RN 3 tested positive for COVID and was quarantined at home)." RN 4 stated that he is a clinical supervisor and that if he had a staff member have any of the symptoms diarrhea, nausea, fever, cough, runny nose, loss of taste or smell, "any symptoms I would get [meaning send] them home." RN 4 stated before Pt 1 was placed on respiratory isolation 9/4/20 and required 2-3 staff members to help get her up, she was having a lot of coughing, staff had "eye protection majority of the time but not all of the time" and surgical masks but "some of the staff were lackadaisical (carelessly lazy) on eye wear, there was a feeling that they [all patients] had all been tested [for COVID and were negative]."

During an interview on 10/7/20, at 9:37 a.m., with RN 2, RN 2 stated, " ...symptoms [for COVID-19] started on Wednesday September 2nd ...last day worked was Monday August 31st ...I called employee health on September 3rd and got tested and was off [came back positive] ..." RN 2 stated she took care of Pt 1 on 8/25/20 and 8/30/20. RN 2 stated, "Employee health did ask who I had cared for and what staff I may have come in contact with." RN 2 stated Pt 1 did not wear a mask and was coughing frequently and was not on isolation on 8/25/20 nor 8/30/20.

During an interview on 10/7/20, at 10:10 a.m., with RN 1, RN 1 stated, "There was an outbreak [multiple staff members became COVID positive in a short amount of time] of COVID at our hospital and it was never announced. I was not told by my manager. I found out from other staff about it a week later ... I went into her (Pt 1) room multiple times, she was coughing frequently and was not wearing a mask. I helped that patient in and out of bed ... I had a thin surgical mask on." RN 1 stated she asked three different times to speak with her manager and her manager never got back to her. RN 1 stated she worked with RN 2 on 8/29/20 and had conversations with her throughout her shift where she was only 2-3 feet away from RN 2 and sometimes for 5-10 minutes long. RN 1 stated they both had their surgical masks on during the conversations and was informed later that RN 2 was positive for COVID-19. RN 1 stated she was never advised by Employee Health about being tested. RN 1 stated she asked employee health on two separate occasions if she could be tested and was informed that they would not test her unless she was having symptoms. RN 1 stated she did finally get tested on 9/12/20 and was negative.

During an interview on 10/7/20, at 10:50 a.m., with Medical Doctor (MD) 1, MD 1 stated he thought the loss of taste on 9/9/20 was his first symptom of COVID-19 so he informed Hospital A on 9/10/20 that he started having this symptom on 9/9/20 at the end of his work day. MD 1 stated his onset of symptoms was different from what was reported on the COVID-19 Positive Staff List for Hospital A because he felt his nasal congestion and runny nose on 9/4/20 were related to his allergies, "I get screened [before working], I didn't mention me having a runny nose on the screening process ...". MD 1 stated he was tested on 9/10/20 and was positive, his last day he worked was 9/9/20.

During an interview on 10/7/20, at 3:15 p.m., with the Director of Employee Health Services (DEHS), the DEHS stated staff are required to do their screening process within four hours of coming to work. The DEHS stated the screening process consists of an application called 1st Up CommUNITY that they started using about a month ago (prior they used a paper screening process) that staff must log into and answer questions about COVID signs and symptoms; if they say no to all screening questions then the application shows a green check mark. The employee then must show the application with the green check mark to the screener when they arrive at work. The screener will then check the staff member's temperature. If the staff do not have a green check mark they cannot come into the facility. If a staff member marks yes to a symptom, the application automatically notifies employee health (EH) and advises them to stay home. The DEHS stated EH will be contacting them as well. The DEHS stated we have had staff members go home after work and call us to let us know that they started to have symptoms after work, and we advise them to get tested for COVID and isolate themselves.

During an interview on 10/7/20, at 11:40 a.m. with the DOIP, the DOIP stated that they have been reeducating staff about the screening process, "I think we are going to push if they [staff] have even one symptom to have them report it ..." The DOIP stated that staff members should be reporting their symptoms when they occur to prevent the spread of COVID. We [the Hospital] are having staff sign an "attestation that they [staff] understand their responsibilities and it is up to them to report this [signs and symptoms of COVID]."

During an interview on 10/7/20, at 4 p.m., with the DOIP, the DOIP stated, " ...we [this facility] had two nurses [RN 2 & RN 3] test positive for COVID-19 on 9/3/20. At that time, we didn't know who they were connected to." The DOIP stated RN 2 & RN 3 reported that they had both worked with Pt 1 and she had been coughing and did not wear a mask. Pt 1 was placed on respiratory isolation on 9/4/20 for presumed COVID and tested positive on 9/5/20. The DOIP stated, Pt 1's original COVID test came back negative on 8/22/20. The DOIP stated the facility didn't have three positive staff members until RT 1 came back positive on 9/9/20 and she was part of the exposure list for Pt 1.

During an interview on 10/8/20, at 4 p.m., with RN 5, RN 5 stated, "I had an asthma attack on Monday labor day [9/7/20], Tuesday my doctor adjusted my asthma medications, on Friday [9/11/20] I developed a fever and lost my sense of taste and smell ... Last day I worked was Sunday night the 6th. I work night shift. I tested positive [for COVID] on Monday the 14th."

During an interview on 10/9/20, at 9:25 a.m., with the DOIP, the DOIP stated the contact tracing is started when Pt 1 back positive for the disease, it consisted of first retrieving the electronic medical records for Pt 1, then the next task was to identify the list of all staff that have charted or had contact documented with her. The DOIP stated the next task was to send this list to the manager for the floor the patient is on and in order to identify if anyone else was in contact with Pt 1. The DOIP stated following this task, the list comes back to the infection preventionist to start making calls to those on the list. The DOIP stated staff members who are on this contact list should be contacted within 24 hours of finding out the patient was positive. The DOIP was unsure why it took so long for their facility to contact the Local Public Health Department (reported 9/22/20) and California Department of Public Health (reported 9/23/20) about this outbreak.

During an interview on 10/9/20, at 10:40 a.m., with RN 7, RN 7 stated, "Symptoms started on September 9th (2020), little bit of a cough, we were being evacuated due to the creek fire ... On the 10th I woke up with bronchitis symptoms (swelling in breathing tubes- causes coughing). Positive for COVID 10th (September), I have not returned to work. Last day I worked was September 5th, I did call in on September 8th I was evacuating ..." RN 7 stated, "I worked on September 1st, 2nd, and the 5th. I worked with [RN 3] on the 1st and 2nd ... I did help pull her [Pt 1] up in bed with [RN 3] a couple times on the 2nd, I had my surgical mask on ... I found out on the 5th that she [Pt 1] had contact with a positive (COVID) employee and she came back positive ..."

During an interview on 10/9/20, at 11:30 a.m., with RT 1, RT 1 stated, "No one contacted me to tell me that I had been exposed [to Pt 1 who was COVID-19 positive] ... I was not informed until the end of my shift on 9/7/20 that she (Pt 1) was positive [COVID-19]." RT 1 stated she was having headaches two days prior and on 9/7/20 and that evening she woke up with a fever in the middle of the night. RT 1 stated she was tested and was positive for COVID-19 on 9/9/20. RT 1 stated she worked with Pt 1 on 9/2/20 and 9/3/20, Pt 1 was getting respiratory treatments every 4 hours and was on high flow oxygen, " ...she [Pt 1] was coughing quite a bit ... I do consider that aerosolized ..." RT 1 stated she was wearing an N95 that is vented and must wear a surgical mask over it due to that being the only size she is fitted for. RT 1 stated she wore a PAPR (Powered Air Purifying Respirator- worn for high-risk aerosol-generating procedures-those procedures that are more likely to generate higher concentrations of infectious respiratory aerosols than just coughing, sneezing, talking and breathing) due to the headache she was having on 9/7/20 which was unusual for her; but due to her headache she was unable to wear an N95.

During an interview on 10/9/20, at 2:30 p.m., with the Assistant Chief Nursing Officer (ACNO), the ACNO stated Pt 1 came back COVID-19 positive on 9/5/20 and the staff exposure list for her was finalized on 9/7/20. The ACNO stated, "it should take less than 24 hours for staff to be notified [that they have been exposed to a COVID-19 positive patient]." The ACNO stated, "I do believe the respiratory therapist should have been informed before she came to work that she was exposed to a COVID [positive] patient."

During an interview on 10/9/20, at 2:40 p.m., with the Director of Respiratory Care (DRC), the DRC stated he was informed about the COVID-19 positive patient (Pt 1) on 9/10/20 by email from either employee heath or the infection preventionist. The DRC stated that this was unusual because the usual notifications about positive employees and patients were sent within minutes. The DRC stated he did not know why there was a delay.

During a concurrent interview and document review, on 10/9/20, at 4 p.m., with the DOIP, the COVID-19 positive patients list (patient list for Hospital A), no date, was reviewed. The patient list indicated Pt 1 was positive for COVID-19 on 9/5/20. The DOIP stated all staff who were considered exposed to Pt 1 should have been notified within 24 hours after Pt 1's test came back positive. The DOIP was unaware that RT 1 had not been informed of her exposure to Pt 1 who was COVID-19 positive on 9/5/20. The DOIP stated she did not know RT 1 found out at the end of her shift on 9/7/20 that Pt 1 was COVID-19 positive. The DOIP stated RT 1 should have been informed before coming back to work. The DOIP stated that RT 1 should not have come into work if she was having headaches and was exposed and since she did, she could have possibly exposed other staff and patients she was around on 9/7/20. The document titled, COVID-19 positive staff list, no date, was reviewed with the DOIP. The DOIP confirmed RT 1 tested positive for COVID-19 on 9/9/20, symptoms started on 9/7/20 per the COVID-19 positive staff list.

During a concurrent interview and document review on 10/9/20, at 4:15 p.m., with the DOIP, the document reviewed was a list of staff members that were scheduled to be tested on 9/12/20. The DOIP stated "35 staff members were tested for COVID on 9/12/20 to make sure we checked everyone who may have had contact with the patient [Pt 1]." The document indicated and the DOIP confirmed there were 37 names on this list and one staff member had date tested of 9/10/20 and two had date tested 9/14/20. The DOIP stated the staff member on 9/10/20 was symptomatic and was tested early and the two staff on 9/14/20 were unable to come in on the 12th. The DOIP confirmed that all three of these staff members (RT 2, RN 5, & RN 6) came back COVID positive. The DOIP gave no explaination why it took so long to test these staff members since Pt 1 tested positive on 9/5/20 and the exposure list was ready as of 9/7/20, she did state the hospital just wanted to make sure they tested everyone Pt 1 may have come in contact with.

During a review of the hospital's policy and procedure titled, Universal Masking and Eye Protection Policy, dated 4/6/20, indicated, " ... To ensure [this hospital name] is in compliance with masking guidelines set by the Centers for Disease Control & Prevention (CDC) as well as the [County name] County Department of Public Health recommendation for universal masking and eye protection ... provide guidance for clinical and nonclinical staff to comply with ... universal masking [everyone if able should wear a mask], in combination with hand hygiene [washing hands with soap and water for 20 seconds or using hand sanitizer to keep hands clean and disinfected] and social distancing [keeping 6 feet apart from others] ... to protect our patients, healthcare workers and visitors by reducing the risk of transmitting COVID-19 by symptomatic [having symptoms of the disease] and asymptomatic [not having symptoms but also having the disease] individuals ... III. POLICY ...F. Eye protection shall be worn in all patient care areas and for all direct patient care services ...V. PROCEDURE ... F ... 2. Extended use of eye protection between patient encounters is recommended. Eye protection may be worn continuously throughout the day, in all areas of the hospital and during care of all patients ..."

During a review of the hospital's policy and procedure titled, Infection Prevention Plan - (name of hospital), dated 7/2/19, indicated, " ...XV. EPIDEMIOLOGICAL (OUTBREAK) INVESTIGATION A. An epidemiological investigation is to be conducted whenever a cluster of HAIs [Health Care Associated Infections] has been identified ... C. Steps in conduction an outbreak investigation: ... 3 ... g. Report any outbreaks or unusual infectious disease occurrences to the County Public Health Department as necessary ..."

During a review of the hospital's documents titled, Procedure: Employee Contact Tracing (undated), was reviewed. The Employee Contact Tracing indicated, " ... Procedure: 1. Receive assignment on who to call (Identified in Log [COVID-19 Positive Employee Log] 2. Complete information which is available in the Log for source employee-including the exposure period. 3. Interview employee ... b. Looking for any true exposure which includes i. Close contact: [less than sign] 6 feet apart, for a time [equal or less than] 15 minutes, and ii. Either one, or both parties are not masked. iii. If source employee was wearing non-valve N95, there is no exposure to others ... 4. If valid patient exposures: a. Compete Patient Exposure Log b. Save ... "Exposed Patient Logs" ... 5 If valid employee exposures: a. Complete Employee Exposure Log b. Save ... "Exposed Employee Log" ... 6. Do not email until the Manager Notification email has been sent to the Manager ... 7. "Rely to ALL" on the Manager Notification email. 8. Add [name of hospital] Infection Prevention to the CC of the email 9. Add the source employee initials to the end of the subject line ... 10. Access "Script and Emails Templates" document. 11. Select template which matches situation (Employee exposure list; Patient exposure only; Employee and Patient exposure; or No exposures) Copy and paste into the body of email, fill in appropriate names ... 12. Attach completed log ... 13. Send email 14. Complete Log with dates and any helpful comments regarding the tracing."

During a review of the hospital's document titled, CPI Role in Contact Tracing, revised date 10/8/20, was reviewed. The CPI Role in Contact Tracing is referred to by Hospital A as a process map. This document is set up in a flow chart with titles along the left side of the form such as: Initial Review; Contract Tracing Interview; Patient Exposure; Employee Exposure. This flow chart is supposed to be used with the document Procedure: Employee Contact Tracing.

During a review of the Council of State and Territorial Epidemiologists (CORHA), dated July 15, 2020, the CORHA indicated, " ...thresholds [a point at which a disease will start to spread] are intended to expedite facilities' investigation of COVID-19 cases and reporting to public health authorities, thus ensuring early detection of possible outbreaks and timely intervention to prevent virus' spread ... FOR ACUTE CARE HOSPITALS AND CRITICAL ACCESS HOSPITALS Threshold for Reporting to Public Health ... [equal or greater than] 2 cases of confirmed COVID-19 in a patient 7 or more days after admission for a non-COVID condition with epi-linkage [having the potential to have been cared for by common healthcare providers (HCP)]; [equal or greater than] 2 cases of confirmed COVID-19 in HCP with epi-linkage [ ...potential to have been within 6 feet for 15 minutes or longer in while working in the facility during the 14 days prior to the onset of symptoms ...]. Outbreak Definition ... [equal or greater than] 2 cases of confirmed COVID-19 in HCP with epi-linkage who do not share a household and are not listed as a close contact of each other outside of the workplace during standard case investigation or contact tracing."

During a review of the Centers for Disease Control and Prevention Coronavirus Disease, Infection Control Guidance, updated July 15, 2020, indicated " ... 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic ... Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 ... symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 ... Actively take their temperature and document absence of symptoms consistent with COVID-19 [no symptoms of COVID-19] ... Ask them if they have been advised to self-quarantine [stay home away from others for 14 days] because of exposure to someone with SARS-CoV-2 [COVID-19] infection. Properly manage anyone with symptoms of COVID-19 or who has been advised to self-quarantine: HCP [healthcare provider] should return home and should notify occupational health services to arrange for further evaluation."

During a review of the Centers for Disease Control and Prevention (CDC). Coronavirus Disease 2019 (COVID-19) ... Managing Investigations During an Outbreak, Updated July 31, 2020, it indicated, " ...CDC has developed specific guidance for investigating clients with COVID-19 in a number of settings ... A COVID-19 outbreak indicates potentially extensive transmission within a setting or organization ... A recommended definition is a situation that is consistent with either of two sets of criteria: During (and because of) a case investigation and contact tracing, two or more contacts are identified as having active COVID-19, regardless of their assigned priority; OR. Two or more patients with COVID-19 are discovered to be linked and the linkage is established outside of a case investigation and contact tracing (e.g., two patients who received a diagnosis of COVID-19 are found to work in the same office, and only one or neither of the them was listed as a contact to the other)."

During a review of the facility's Mitigation Plan titled, Hospital A COVID-19 Mitigation Plan (undated), received on 10/6/20, indicated, "Contents ... 2. Testing and Cohorting [placing those with the same disease in the same room] ... the practice of this facility is to protect our patients, staff and any others ... from harm during emergencies or incidents. To accomplish this, we have developed procedures for testing all pre-procedural patients that will require services or admission to [name of Hospital]. This testing is done prior to the procedure ..." If test results are positive patient must consult their primary care physician prior to admit and the surgical case or procedure. "Other admits from other hospitals are required to have ... "negative" COVID-19 test prior to ... admission. In rare case ... suspected COVID-19 or turns into a positive COVID-19 patient, they will be placed into isolation and a transfer order will be placed for movement to [Sister Facility Name] for further care and treatment ... This facility will report any positive test in accordance with the current local health department and CDPH [California Department of Public Health] guidance ... 3 Testing Staff ... we have developed procedures for testing symptomatic staff that may have either had an exposure or screen out of daily health screening. Staff ... coordinate with ... Employee Health Services (EHS) for a brief interview ... be screened and tested for COVID-19 ... employee will be placed on quarantine until test results are returned ... All staff have completed training and an attestation regarding the signs and symptoms of COVID-19 and their responsibility to monitor their health. Employees must complete a health screening and active temperature monitoring before starting their shift each day ... 5 Infection Prevention and Control ... manage COVID-19 at [name of hospital] ...heavily influenced from the local health department, CDPH, and the CDC ...Employee Health Services and Infection Prevention (IP) will maintain a line list of all patients and staff who are confirmed COVID-19 positive ... All persons entering the facility will be checked for temperatures and screened for COVID-19 symptoms ..."