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A. Based on observation, and staff interview it was determined the facility failed to maintain a sanitary environment by not addressing cleanliness issues for the prevention of the spread of Coronavirus Disease-19 (COVID-19) which public health authorities have designated as a pandemic. This failure places all patients, visitors, and staff at risk for serious harm and/or death from infection with COVID-19.

Findings include:

On entering the facility on 1/25/21 at 10:05 a.m., state surveyors noted there was no hand sanitizer in the entry of the facility or the lobby. There was no bathroom in the lobby or visible from the lobby to clean hands. There were no tissue stations and no covered waste baskets available for the disposal of tissues.

A tour was conducted on 1/25/21 at 10:45 a.m. with the Infection Control Preventionist Manager and the Director of Inpatient Services for the facility. The staff were unable to show the surveyor a hand sanitizer station in the entry of the facility or the lobby. The Director of Inpatient Services noted there was a bathroom for handwashing, but it was located in a hallway beyond the outpatient area and was not well marked from the lobby. The security guard showed the surveyor hand sanitizer they kept in a drawer in the entry and stated they "did not keep it out as people had a tendency to use too much."

During the tour on 1/25/21 at 10:45 a.m., the Infection Control Preventionist Manager and the Director of Inpatient Services acknowledged there was no hand sanitizer for use in the entry of the facility or lobby for staff and visitors. They acknowledged there was no bathroom in the lobby or near the lobby. They stated there was a bathroom located around the corner from the lobby past the outpatient registration desks, but acknowledged it was not well marked. They concurred there were no tissue stations or waste baskets for disposal of tissues in the entry or lobby.

A phone interview was conducted with the Director of Inpatient Services on 1/26/21 at 7:35 a.m. They stated the facility mainly follows CDC guidelines.

B. Based on observation and staff interview it was determined the facility failed to ensure measures were put in place reflecting the scope and complexity of the facility, which specializes in Psychiatric services, to prevent the spread of Coronavirus Disease-19 (COVID-19). This failure places all patients, visitors, and vendors at risk for infection with COVID-19 resulting in serious harm and/or death.

Findings include:

On entering the facility on 1/25/21 at 10:05 a.m., the surveyors were not screened for COVID-19. Observation revealed there was no hand sanitizer in the entry of the facility or the lobby. No bathroom was located in the lobby to wash hands.

A tour was conducted on 1/25/21 at 10:45 a.m. with the Infection Control Preventionist Manager and the Director of Inpatient Services for the facility. An individual was noted entering the facility. They were not screened for COVID-19. The staff were unable to show the surveyor a hand sanitizer station in the entry to the facility or the lobby. The Director of Inpatient Services noted there was a bathroom for handwashing, but it was located in a hallway beyond the outpatient area and was not well marked from the lobby. The security guard showed the surveyor hand sanitizer they kept in a drawer in the entry and stated they "did not keep it out as people had a tendency to use too much."

An interview was conducted with the Infection Control Preventionist Manager and the Director of Inpatient Services during observations on 1/25/21 at 10:45 a.m. They stated they have not done any COVID-19 screening at the entry point to the facility at any time during the pandemic. They stated one (1) reason the facility did not keep hand sanitizer in the lobby was to prevent drinking of the solution by patients. They concurred the bathroom closest to the lobby, located around the corner from the lobby past the outpatient registration desks, was not well marked so visitors, vendors and patients could wash their hands.

C. Based on observation, staff interview and document review it was determined the facility failed to ensure Centers For Disease Control and Prevention (CDC) guidelines were used to form policies and procedures for the prevention and control of Coronavirus Disease-19 (COVID-19). This failure places all patients and visitors at risk for serious harm and/or death from infection with COVID-19.

Findings include:

On entering the facility on 1/25/21 at 10:05 a.m., the surveyors were not screened for COVID-19. Observation revealed there was no hand sanitizer in the entry or the lobby. There were no tissue stations and no covered waste baskets available for the disposal of tissues in the entrance or lobby. No bathroom was located in the lobby.

A tour was conducted on 1/25/21 at 10:45 a.m. with the Infection Control Preventionist Manager and the Director of Inpatient Services. An individual was noted entering the facility. They were not screened for COVID-19. The staff were unable to show the surveyor a hand sanitizer station in the entry of the facility or the lobby. The Director of Inpatient Services stated there was a bathroom for handwashing, but it was located in a hallway beyond the outpatient area and was not well marked from the lobby. The security guard showed the surveyor hand sanitizer they kept in a drawer in the entry and stated they "did not keep it out as people had a tendency to use too much."

An interview was conducted during the tour on 1/25/21 at 10:45 a.m. with the Infection Control Preventionist Manager and the Director of Inpatient Services. They revealed the facility has never screened visitors and staff at the entrance for COVID-19. They stated screening has not been done at any time during the COVID-19 pandemic.

A phone interview was conducted on 1/25/21 at 4:45 p.m. with the Manager of Employee Health. They revealed the facility's definition of an exposure includes distance of contact three (3) feet or less. They stated their understanding of the definition of exposure was contact equaling fifteen (15) minutes during one (1) encounter.

A WebEx interview was conducted on 1/26/21 at 9:30 a.m. Attending were the facility's Infection Control Preventionist, the Manager of Employee Health, the Assistant Vice President for Center for Quality Outcome, the Risk Manager, a staff member who works with Workers Compensation and their supervisor, the Medical Director of Quality and Patient Safety and the Hospital Epidemiologist and Infectious Disease Expert. The following was revealed during the interview:

The Infection Control Preventionist stated the facility mainly follows CDC guidelines.

The Assistant Vice President for Center for Quality Outcome stated the facility uses a three (3) foot or closer rule to define an exposure.

The Hospital Epidemiologist and Infectious Disease Expert stated the three (3) foot rule is followed instead of CDC guidelines. They stated the decision not to follow CDC guidelines to define an exposure with a six (6) foot or closer rule was based on a study the hospital system had conducted, the fact that respiratory viruses travel three (3) feet and if you tried to maintain a six (6) foot distance, staff would have to stand outside a patient room if the hospital was small.

The Manager of Employee Health stated the facility defines exposure to COVID-19 as two (2) unmasked persons, three (3) feet or closer to each other and a duration of contact time of fifteen (15) minutes. They stated the same definition would be applied to determine if an exposure occurred in the community.

The Assistant Vice President for Center for Quality Outcome acknowledged there is no system currently in place to audit staff's knowledge of COVID symptoms. They stated the facility is not conducting audits to determine the level of staff compliance with self-screening.

A phone interview was conducted with the Director of Inpatient Services and the Manager of Employee Health on 1/26/21 at 7:35 a.m. The Director of Inpatient Services stated the facility does not screen inpatients for COVID-19 daily. They stated they were not aware this was a CDC guideline.

A review of a document, titled "West Virginia University Hospitals Chestnut Ridge Center Policy and Procedure Manual", last reviewed 3/13/20, states in part: "A. To prevent the spread of healthcare-associated or community acquired organisms and/or infections within the hospital through evidence-based research and practice. B. To prevent the exposure of patients, visitors, employees, students and volunteers to communicable or infectious diseases ... Respiratory Etiquette guidelines include ... Provide tissues and provide receptacles for disposal of used/soiled tissues ... Make hand hygiene products available ... Encourage persons with respiratory symptoms to stay at least 3 feet from other persons ... Implementation of this policy will be the responsibility of the Nurse Supervisors, Managers and Directors of Chestnut Ridge Center Inpatient units."

A review of a document, titled "WVUH Infection Control Plant", last reviewed 6/19, states in part: "West Virginia University Hospital Infection Control (IC) Program ... Incorporates evidence-based practices from leading authorities in infection prevention including the Centers for Disease Control and Prevention (CDC)."

A review of a document, titled "COVID Screening for Chestnut Ridge {SECURE}", dated 1/27/21 at 11:26 a.m., states in part: "We do not have a screening policy for Chestnut Ridge."

A review of a document, titled "Frequently Asked Questions", obtained from the CDC website and last updated 1/19/21, states in part: "For COVID-19, a close contact is anyone who was within [six] 6 feet of an infected person for a total of [fifteen] 15 minutes or more ... People with COVID-19 can still spread the virus even if they don't have symptoms. If you were around someone who had COVID-19, it is critical that you stay home and away from others for [fourteen] 14 days from the last day that you were around that person."

A review of a document, titled "COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 1019 (COVID-19) Pandemic", updated 12/14/20, states in part: "Establish a process to ensure everyone (patients, healthcare personnel and visitors) entering the facility is assessed for symptoms of COVID-19, absence of a diagnosis of SARS-CoV-2 in the prior [ten] 10 days and confirm they have not been exposed to others with SARS-CoV-2 infection during the prior [fourteen] 14 days."

D. Based on staff interview it was determined the facility failed to ensure staff were following procedures established for self-screening for Coronavirus Disease-19 (COVID-19) symptoms before reporting to work. This failure places all patients and staff at risk for infection with COVID-19 facilitating spread of the disease and resulting in serious harm and/or death.

Findings include:

An interview was conducted with Environmental Services Worker #1 on 1/25/21 at 1:55 p.m. When asked how they self-screen for COVID-19 before reporting for each work shift, they stated in part, "That's all I do. I take my temperature."

A phone interview was conducted with the Manager of Employee Health on 1/25/21 at 4:45 p.m. They stated the facility has a six (6) day a week hotline staff can call if they have COVID-19 symptoms. They stated there is also an app for cell phones which is accessible to all staff. They stated staff were educated about the app in March 2020. They stated staff have been educated about changes in Centers for Disease Control and Prevention (CDC) updates as they occur. They stated the facility screens staff reports of exposure and depending on level of exposure, decides how the staff member should proceed (whether or not to quarantine and how long). They stated the facility definition of exposure included both persons unmasked during their encounter and at a distance of three (3) feet.

A phone interview was conducted with the Director of Inpatient Services and the Regulatory Coordinator on 1/26/21 at 7:35 a.m. The Director of Inpatient Services stated the facility uses CDC guidelines.

A WebEx interview was conducted on 1/26/21 at 9:30 a.m. Attending were the facility's Infection Control Preventionist, the Manager of Employee Health, the Assistant Vice President for Center for Quality Outcome, the Risk Manager, a staff member who works with Workers Compensation and their supervisor, the Medical Director of Quality and Patient Safety and the Hospital Epidemiologist and Infectious Disease Expert. The following was revealed during the interview:

The Infection Control Preventionist stated the facility mainly follows CDC guidelines.

The Assistant Vice President for Center for Quality Outcome stated the facility uses a three (3) foot or closer rule to define an exposure. The Hospital Epidemiologist and Infectious Disease Expert stated the three (3) foot rule is followed instead of CDC guidelines. They stated the decision not to follow CDC guidelines to define an exposure with a six (6) foot or closer rule was based on a study the hospital system had conducted, the fact that respiratory viruses travel three (3) feet and if you tried to maintain a six (6) foot distance, staff would have to stand outside a patient room if the hospital was small.

The Manager of Employee Health stated the facility defines exposure to COVID-19 as two (2) unmasked persons, three (3) feet or closer to each other and a duration of contact time of fifteen (15) minutes. They stated the same definition would be applied to determine if an exposure occurred in the community.

The Assistant Vice President for Center for Quality Outcome acknowledged there is no system currently in place to audit staff's knowledge of COVID symptoms to monitor for self-screening. They stated the facility is not conducting audits to determine the level of staff compliance with self-screening.

A phone interview was conducted with Environmental Services Worker #2 on 1/27/21 at 11:32 a.m. They stated they were hired after the COVID-19 pandemic. They stated they did attend orientation. They stated they do not self-screen for COVID-19. They stated they were never told there is a phone app which can be used to do self-screening and they think the app is a good idea.

A phone interview was conducted with Environmental Services Worker #3 on 1/27/21 at 11:41 a.m. They stated they were hired in April 2020 after COVID-19 became a pandemic. They stated they did attend orientation. They stated they never do self-screening and has never been told there is a phone app for screening.