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A. Based on observation, staff interview, and document review, it was determined that the facility failed to maintain its infection prevention and control program in accordance with nationally recognized infection control guidelines during the COVID-19 pandemic for two of two occurrences.

Findings include:

Reference: CDC [Centers for Disease Control and Prevention] Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic states, "...Encourage Physical Distancing Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. ... Examples of how physical distancing can be implemented for patients include: ... Arranging seating in waiting rooms so patients can sit at least 6 feet apart. Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by implementing virtual methods (e.g., video format for group therapy) or scheduling smaller in-person group sessions while having patients sit at least 6 feet apart."

1. During an observation on 11/24/2020 on 1 North, more than four (4) patients were observed sitting immediately next to each other in a communal area. The seats were not arranged so patients can sit at least 6 feet apart.

2. During an observation on 11/24/2020 on 1 Center, more than three (3) patients were observed sitting immediately next to each other in a communal area. The seats were not arranged so patients can sit at least 6 feet apart.

3. Staff #3 confirmed the above findings.

B. Based on observations, staff interview, and review of Manufacturer's Instructions for Use (IFU) conducted on 11/24/2020, it was determined that the facility failed to ensure that manufacturer's instructions for use on the disinfectant wipes are followed, in accordance to Centers for Disease Control and Prevention (CDC) Guidelines for one of one occurrence.

Findings include:

Reference: CDC [Centers for Disease Control and Prevention] Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 page 84 states, "Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA [environmental protection agency]-registered hospital disinfectant using the label's safety precautions and use directions. ... By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability from any injuries resulting from the off-label use and is potentially subject to enforcement action under FIFRA."

1. During an observation on 11/24/2020 in the entrance area, the following was observed:

a. At 10:00 AM, Staff #9 was observed using an oral SureTemp Welch Allyn thermometer, a noncritical medical device to take a temperature on a staff member then cleaning the oral thermometer using a Fresh Start Disinfectant wipe.

b. Staff #9 was questioned about the required contact time for the disinfectant wipes he/she was using. Staff #9 stated, "there is no contact time, not that I know of."

c. Review of the manufacturer's label instructions indicated, "Fresh Start is an effective virucide on hard, non-porous surfaces against Human Coronavirus (ATCC VR-740) when the treated surface is allowed to remain wet for 10 minutes. Allow surfaces to air dry."

2. This finding was confirmed with Staff #2, Staff #3, and Staff #4.