The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CENTRAL MAINE MEDICAL CENTER 300 MAIN STREET LEWISTON, ME 04240 Aug. 10, 2020
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document reviews, observations, and interviews, it was determined that the Condition of Participation for Governing Body was not met as evidenced by the Governing Body's failure to provide oversight of the hospital as evidenced by the failure to implement all possible strategies to prevent and control the transmission of COVID-19; to ensure that the prevention and control program included surveillance; to ensure the maintenance of a clean and sanitary environment; and to ensure documention of infection control rounds. It was determined that the hospital's failures constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

The Governing Body has failed to provide oversight of the hospital as evidenced by the following:

1. Condition: 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs also known as A-0747 - Based on document reviews, observations, and interviews, it was determined that the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was not met as evidenced by the hospital's failure to implement all possible strategies to prevent and control the transmission of COVID-19; to ensure that the prevention and control program included surveillance; to ensure the maintenance of a clean and sanitary environment; and to ensure documention of infection control rounds. It was determined that the hospital's failure to implement all possible strategies to prevent and control the transmission of COVID-19, to conduct surveillance for infection control, and to provide a clean and sanitary environment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0747 for details.

2. Standard: 482.42(a)(2) Infection Control Program also known as A-0749 - Based on document reviews, observations, and interviews, the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19. It was determined that the hospital's failure to implement all possible strategies constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0749 for details.

3. Standard: 482.42(a)(3) Infection Control Surveillance, Prevention also known as A-0750 - Based on document reviews, observations, and interviews, the hospital has failed to ensure that the prevention and control program included surveillance to ensure all strategies prevent and control the transmission of COVID-19 were implemented and failed to ensure the maintenance of a clean and sanitary environment in the Intensive Care Unit. It was determined that the hospital's failure to ensure surveillance and a clean environment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0750 for details.

4. Standard: 482.42(c)(1) Leadership Responsibilities (Governing Body) also known as A-0770 - Based on document reviews, observations, and interviews, the hospital's Governing Body failed to ensure that the hospital had systems in place to ensure all possible strategies to prevent and control the transmission of COVID-19 were implemented and monitored and failed to ensure systems were in place to maintain a clean and sanitary patient environment. See A-0770 for details.

5. Standard: 482.42(c)(2) Leadership responsibilities (Infection Preventionist) also known as A-0772 - Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to implement infection control strategies to prevent and control the transmission of COVID-19 and to monitor the strategies (surveillance) as per the United States Centers for Disease Control and Prevention guidance. See A-0772 for details.

6. Standard: 482.42(c)(2)(ii) Infection Control Professional Documentation also known as A-0773 - Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to ensure documention of infection control rounds. See A-0773 for details.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.

The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on document reviews, observations, and interviews, it was determined that the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs was not met as evidenced by the hospital's failure to implement all possible strategies to prevent and control the transmission of COVID-19; to ensure that the prevention and control program included surveillance; to ensure the maintenance of a clean and sanitary environment; and to ensure documention of infection control rounds. It was determined that the hospital's failures constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

1. Standard: 482.42(a)(2) Infection Control Program also known as A-0749 - Based on document reviews, observations, and interviews, the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19. It was determined that the hospital's failure to implement all possible strategies constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0749 for details.

2. Standard: 482.42(a)(3) Infection Control Surveillance, Prevention also known as A-0750 - Based on document reviews, observations, and interviews, the hospital has failed to ensure that the prevention and control program included surveillance to ensure all strategies prevent and control the transmission of COVID-19 were implemented and failed to ensure the maintenance of a clean and sanitary environment in the Intensive Care Unit. It was determined that the hospital's failure to ensure surveillance and a clean environment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0750 for details.

3. Standard: 482.42(c)(1) Leadership Responsibilities (Governing Body) also known as A-0770 - Based on document reviews, observations, and interviews, the hospital's Governing Body failed to ensure that the hospital had systems in place to ensure all possible strategies to prevent and control the transmission of COVID-19 were implemented and monitored and failed to ensure systems were in place to maintain a clean and sanitary patient environment. See A-0770 for details.

4. Standard: 482.42(c)(2) Leadership responsibilities (Infection Preventionist) also known as A-0772 - Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to implement infection control strategies to prevent and control the transmission of COVID-19 and to monitor the strategies (surveillance) as per the United States Centers for Disease Control and Prevention guidance. See A-0772 for details.

5. Standard: 482.42(c)(2)(ii) Infection Control Professional Documentation also known as A-0773 - Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to ensure documention of infection control rounds. See A-0773 for details.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document reviews, observations, and interviews, the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19. It was determined that the hospital's failure constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

On 7/29/2020, the Division of Licensing and Certification was made aware of an outbreak of COVID-19. An on-site investigation was initiated.

On 7/29/2020 at 9:35 AM, the System Director of Infection Prevention stated, the hospital had four (4) patients who were COVID-19 positive, one (1) patient who was an person under investigation, and an outbreak of twelve (12) staff members who were COVID-19 positive.

This survey identified the following:

1. The United States Centers for Disease Control and Prevention (US CDC)'s "Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, indicated all facilities "screen everyone (patients, HCP [Health Care Personnel], visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control" and "actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature 100.0F or subjective fever".

On 7/29/2020 at 9:25 AM and 9:30 AM, surveyors were screened at the Main Entrance (60 High St.) of the hospital. Surveyors were asked about COVID-19 symptoms but the temperature of the surveyors was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/29/2020 at 9:25 AM, surveyors observed visitors being screened at the Main Entrance (60 High St.) of the hospital. The visitors were asked about COVID-19 symptoms but the temperature of the visitors was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/29/2020 at 9:25 AM, 9:30 AM, and 11:00 AM, surveyors observed visitors being screened at the Main Entrance (60 High St.) of the hospital. The visitors were asked about COVID-19 symptoms but the temperature of the visitors was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/29/2020 at 10:53 AM, a surveyor observed visitors being screened at the 12 High Street of the hospital. The visitors were asked about COVID-19 symptoms but the temperature of the visitors was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/29/2020 at 12:30 PM, a surveyor observed an employee enter at the Main Entrance (60 High Street). The employee was not screened upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:00 AM, surveyors were screened at the Main Entrance of the hospital surveyors were not asked about COVID-19 symptoms but the temperature of the surveyors was taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:00 AM, surveyors observed employees enter the Main Entrance (60 High Street) of the hospital. Employees were not screened upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:05 AM and 6:10 AM, surveyors observed employees enter the Main Entrance (60 High Street) of the hospital. Employees were not screened upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:20 AM, surveyors were screened at the 12 High Street entrance. Surveyors were asked about COVID-19 symptoms but the temperature of the surveyors was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:20 AM, surveyors observed patients being screened at the 12 High Street entrance. The patients were asked about COVID-19 symptoms but the temperature of the patients was not taken upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:20 AM, surveyors observed an employee enter at the 12 High Street entrance. The employee was not screened upon entrance to the hospital, per the CDC screening recommendations.

On 7/30/2020 at 6:35 AM, surveyors entered the Emergency Department (ED) entrance and observed staff also entering through this entrance. No screener was present; therefore, no screening was conducted at this entrance per the CDC screening recommendations.

On 7/30/2020 at 6:41 AM, surveyors observed several employees walking towards another possible point of entry. Between 6:43 AM and 7:00 AM, surveyors observed multiple staff, including the System Director of Quality Services, enter through the designated "Employee Entrance", which was badge accessed only. Staff allowed surveyors to enter through this door without confirming who they were. There was no screening at this entrance into the hospital, per the CDC screening recommendations.

On 7/30/2020 at 7:01 AM, surveyors again entered the Emergency Department (ED) entrance. Again, no screener was present; therefore, no screening was conducted at this entrance per the CDC screening recommendations. The surveyors observed that anyone entering this entrance could access the hospital without being screened.

On 7/30/2020 at 11:00 AM, a surveyor observed visitors being screened at the Main Entrance (60 High St.) of the hospital. The visitors were asked about COVID-19 symptoms but the temperature of the visitors was not taken upon entrance to the hospital, per the CDC screening recommendations.

Surveyors requested any written policy/protocol/procedure in relation to screening. An email, dated 6/10/2020, was given to surveyor which stated "We are refining our entry process for team members after receiving valuable feedback on our process. Reflecting new policies at many other health systems, we will no longer be performing temperature checks as of Friday, June 12th".

An email, dated 6/24/2020, was provided to surveyors. This email stated, "Temperatures are no longer utilized as a screening tool. Team members will not be screened for symptoms ...patients and allowed visitors will be questioned about symptoms, provided with masks if they do not have them; and will go directly to their appointment ....you [team members] will be required to complete a one-time online screening tool. The process for team members has been updated. Please remember to enter the premises only through authorized entrances when you report to work. We have opened up additional doors ...the following entrances are now open via badge access only: Doctors Parking Level, Employee Entrance by the ED, Linen Doors on Lower Level Near Parking Garage and Delivery Door into the MOB".

On 7/29/2020 at 11:15 AM, the Critical Care Manager stated, "We have just started, I think it was the 25th of July, screening staff when they get to the unit, we don't take temperatures ...just a subjective screening for fever. We don't screen lab employees".

On 7/29/2020 at 11:45 AM, a Phlebotomist stated, "We used to get screened before coming into the hospital, but now we wear a mask and if we don't have any of the symptoms, we are good to work. It is an honor system for screening in the morning. There is no screening to come on to this unit or for the lab".

On 7/29/2020, at 2:30 PM, the Regulatory Compliance Coordinator stated the following:

- "Before 6/25/2020, employees were screened at the two main entrances."

- "After that date, we had the employees sign an attestation form one time, electronically, and then the only thing they do daily when they come in is get a new mask, if they don't have one, and complete hand hygiene".

- "There are three entrances that staff use to come to the hospital which is 12 High Street (outpatient services), 60 High Street (main entrance) and the ED Entrance, but I don't think many people come through the ED unless they work there".

On 7/30/2020 at 8:05 AM, surveyors asked the hospital's Leadership representatives for clarification of the new screening process for staff. A Leadership representative indicated that the new process began on 7/27/2020, staff would be screened on the unit before they start their shift, and this would be documented.

On 7/30/202 at 8:17 AM, the Interim Nurse Leader of the ED stated, "We are screening staff on the unit prior to them getting their assignment and documenting every shift".

On 7/30/2020 at 8:35 AM, the ED staff assignment schedule and the screening documentation of the ED staff for 7/30/2020 was reviewed. The review revealed there was no evidence that three (3) of eight (8) staff, who were working, had been screened. The lack of documented screening was confirmed by the Interim Nurse Leader at the time of the review.

On 7/30/2020 at 10:10 AM, the T-3, inpatient unit, staff schedule and the screening documentation was requested. The staff assignment schedule for 7/30/2020 was provided which indicated eight (8) staff to be working at 10:10 AM. The screening documentation was not provided. The T-3 Unit Charge Nurse stated, "I did it, but just haven't typed it into the computer yet". When asked how she knew the answers to the screening questions, she stated, "I just remember it" and she confirmed she had not taken notes at the time of screening at the start of the shift.

On 7/30/2020 at 10:20 AM, Certified Nursing Assistant (CNA) #1, who was working on T-3, stated, "The nurse doesn't ask each individual in the huddle about symptoms, it's just a loose question about symptoms".

On 7/30/2020 at 10:25 AM, CNA #2., who was working on T-3, stated "We get screened as a group in huddle".

On 7/30/2020 at 12:55 PM, Environmental Services (EVS) employee #3 , "They don't screen us anymore, they used to screen us, and take our temperature".

2. The US CDC's "Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, indicated all facilities should "limit and monitor points of entry to the facility."

On 7/29/2020, at 2:30 PM, the Regulatory Compliance Coordinator stated "There are three entrances that staff use to come to the hospital which is 12 High Street, 60 High Street (Main Entrance) and the ED Entrance.

An email, dated 6/24/2020, was provided to surveyors. This email stated, "We have opened up additional doors ...the following entrances are now open via badge access only: Doctors Parking Level, Employee Entrance by the ED, Linen Doors on Lower Level Near Parking Garage and Delivery Door into the MOB [Medical Office Building]".

On 7/30/2020 at 6:35 AM, surveyors entered the ED entrance and observed staff also entering through this entrance. There was no monitoring of this entrance, per the CDC screening recommendations.

On 7/30/2020 at 6:41 AM, surveyors observed several employees walking towards another possible point of entry. Between 6:43 AM and 7:00 AM, surveyors observed multiple staff, including the System Director of Quality Services, enter through the designated "Employee Entrance", which was badge accessed only. Staff allowed surveyors to enter through this door without confirming who they were. There was no monitoring of this entrance, per the CDC screening recommendations.

On 7/30/2020 at 7:01 AM, surveyors again entered the Emergency Department (ED) entrance. Again, this entrance was not monitored, per the CDC screening recommendations.

On 7/30/2020 at 10:45 AM, the System Director of Infection Prevention stated, that Incident Command restricted entrances for employees until a few weeks ago when they opened up all employee entrances as before with badge access only.

3. The US CDC's "Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, indicated fever is a measured temperature at 100.0 degrees Fahrenheit (F).

On 6/29/2020, surveyors requested hospital policies/protocols/procedures related to COVID-19. One of the documents received was the "Outpatient Assessment and management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID - 19)" which states when assessing the patient look for a fever of 100.4 degrees F.

On 7/30/2020 at 6:36 AM, a sign in the ED entrance was observed that instructed the reader to tell the Triage Nurse if you have an elevated temperature of 100.4 degrees F.

On 7/30/2020 at 10:45 AM, the System Director of Infection Prevention was interviewed and was asked about the temperature of 100.4 degrees F on the sign. She stated that she is following CDC and National Health Safety Network guidelines in relation to the temperature. She provided a document titled "Definitions of Symptoms of Reportable Illness", dated 6/30/2017, which indicated the "CDC considers a person to have a fever when he or she has a measure temperature of 100.4 F or greater".

The System Director of Infection Prevention was not aware of the current CDC guidance for fever.

4. The US CDC's "Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, indicated facilities should "post visual alerts (e.g.: signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene."

On 7/29/2020 at 9:25 AM and 9:30 AM and on 7/30/2020 at 6:20 AM, 6:35 AM and 7:01 AM, surveyors observed signs related to COVID-19 at the 12 High Street, 60 High Street, and the ED entrances. However, there was no evidence of any other signs placed strategically within the hospital.

5. The US CDC's "Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 7/15/2020, indicated health care personnel should wear a facemask at all times while they are in the healthcare facility.

On 7/30/2020 at 6:36 AM, one (1) employee was observed entering through the ED entrance without a facemask and proceeded into the hospital without putting a facemask on.

On 7/30/2020 at 6:43 AM, a sign was observed on the Employee Entrance door that stated, "To utilize these doors you must have a mask before entering".

On 7/30/2020 at 6:43 AM, two (2) employees were observed entering through the Employee Entrance and proceeded up the stairs without a facemask.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
Based on document reviews, observations, and interviews, the hospital has failed to ensure that the prevention and control program included surveillance to ensure all strategies prevent and control the transmission of COVID-19 were implemented and failed to ensure the maintenance of a clean and sanitary environment in the Intensive Care Unit. It was determined that the hospital's failure to ensure surveillance and a clean environment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

1. Based on document reviews, observations, and interviews, the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19. See A-0749 for details.


2. On 7/29/2020 between 11:15 AM and 11:45 AM in the Intensive Care Unit, where four (4) confirmed COVID-19 patients and one (1) patient under investigation were being treated, the following was observed in the presence of the Critical Care Manager:

- Visible dirt buildup and many visible dried splatter stains were on the hallway floor, by Rooms #428, #429, and #430

- A used glove was on the bottom of a cart in the hallway

- An opened box was on the hallway floor

- Intravenous (IV) poles, with IV machines attached, were located outside three (3) ICU Rooms (#428, #429, and #430). The tubing from the machine was touching the floor in two (2) of the rooms (Room #428 and #429).

- The floor in Room #428 had brown dried liquid areas, visible dirt, and trash (e.g.: alcohol pads, IV caps, IV bag stoppers, and straw wrappers).

- The floor in Room #429 had several brown dried liquid areas, visible dirt, and trash (e.g.: alcohol pads and IV caps).

On 7/29/2020 at 11:20 AM, the Critical Care Manager stated, the following:

- The housekeeping staff do not go into any patient room that the patient is positive or under investigation for COVID-19;

- The Nurses clean the bedside table and counter tops daily but do not clean the floors;

- The patient in Room #428 has been in the room for ten (10) days and the floor probably had not been clean; and

- The hallway gets mopped twice a week.

On 7/29/2020 at 12:50 PM, Environmental Services (EVS) employee #1 stated, "Patient rooms cleaned daily if occupied, but EVS does not enter patient rooms with COVID-19".

On 7/30/2020 at 10:45 AM, the System Director of Infection Prevention was interviewed in relation to infection control surveillance. She stated, "Infection Preventionist Staff make daily rounds, I am in Administration, to monitor/enforce compliance and report back to the Unit Managers for employee follow-up. There is no documentation for the daily rounds".

On 7/30/2020 at 4:00 p.m., an EVS Employee #2 who stated, all precaution rooms are cleaned every day except COVID-19 rooms which are done after discharge.

On 7/30/2020 between 4:10 PM and 4:30 PM, in the Intensive Care unit, where three (3) confirmed COVID-19 patients and one (1) patient under investigation were being treated, surveyors observed the following:

- Visible dirt buildup and many visible dried splatter stains on the hallway floor by Rooms #428, #429, and #430;

- An overflowing trash can in the hall between ICU Room #429 and ICU Room 430;

- A dirty towel was on the floor inside Room #430;

- A used IV bag was on the floor outside Room #429;

- IV poles, with IV machines attached, were located outside two (2) ICU Rooms (#429, and #430). The tubing from the machine was touching the floor in one (1) of the room (Room #429);

- Brown dried liquid areas, visible dirt, and trash (e.g.: alcohol pads, IV caps, IV bag stoppers, and straw wrappers) on the floor in Room #428.

- The floor in Room #429 had several brown dried liquid areas, a wet area under the foot of the bed, visible dirt, and trash (e.g.: alcohol pads and IV caps).

On 7/30/2020 at 4:35 PM during the exit conference with hospital leadership, the System Director of Infection Prevention stated, "We don't place environmental workers in the COVID-19 positive patient rooms in accordance with CDC Guidelines". When asked if she had made observations in the ICU, she stated, "No, I have not seen it".

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0770
Based on document reviews, observations, and interviews, the hospital's Governing Body failed to ensure that the hospital had systems in place to ensure all possible strategies to prevent and control the transmission of COVID-19 were implemented and monitored and failed to ensure systems were in place to maintain a clean and sanitary patient environment.

Finding:

The Governing Body has failed to ensure that the hospital failed to ensure that the hospital had systems in place to ensure all possible strategies to prevent and control the transmission of COVID-19 were implemented and monitored and failed to ensure systems were in place to maintain a clean and sanitary patient environment. This was evidenced by the following:

1. Based on document reviews, observations, and interviews, the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19. It was determined that the hospital's failure to implement all possible strategies constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. Please see A-0749 for details.

2. Based on document reviews, observations, and interviews, the hospital has failed to ensure that the prevention and control program included surveillance to ensure all strategies prevent and control the transmission of COVID-19 were implemented and failed to ensure the maintenance of a clean and sanitary environment in the Intensive Care Unit. It was determined that the hospital's failure to ensure surveillance and a clean environment constituted an immediate jeopardy situation. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider's noncompliance with one or more health and safety requirements. Please see A-0750 for details.
VIOLATION: IC PROFESSIONAL RESPONSIBILITIES POLICIES Tag No: A0772
Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to implement infection control strategies to prevent and control the transmission of COVID-19 and to monitor the strategies (surveillance) as per the United States Centers for Disease Control and Prevention guidance.

Finding:

On 7/29/2020, the Division of Licensing and Certification was made aware of an outbreak of COVID-19 at the hospital. An on-site investigation was initiated.

Based on observations on 7/29/2020 and 7/30/2020, surveyors determined the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19 and that the hospital failed to ensure a clean and sanitary environment. Please see A-0749 and A-0750 for details.

On 7/29/2020 at 9:35 AM, the System Director of Infection Prevention stated, the hospital had four (4) patients who were COVID-19 positive, one (1) patient who was a person under investigation, and an outbreak of twelve (12) staff members who were COVID-19 positive.

On 7/30/2020 at 10:45 AM, the System Director of Infection Prevention was interviewed regarding employee screening upon entrance to the hospital and the temperature of 100.4 degrees Fahrenheit (F) on signs observed in the hospital. She stated, that Incident Command restricted entrances for employees until a few weeks ago when they opened up all employee entrances as before with badge access only. When asked about the temperature of 100.4 degrees F on the sign, she stated that she is following CDC and National Health Safety Network guidelines in relation to the temperature. She provided a document titled "Definitions of Symptoms of Reportable Illness", dated 6/30/2017, which indicated the "CDC considers a person to have a fever when he or she has a measure temperature of 100.4 F or greater". The System Director of Infection Prevention was not aware of the current CDC guidance for fever which is 100.0 degrees F.

On 7/30/2020 at 4:35 PM during the exit conference with hospital leadership, surveyors discussed observations of an unclean environment in the Intensive Care Unit (ICU). The System Director of Infection Prevention stated, "We don't place environmental workers in the COVID-19 positive patient rooms in accordance with CDC Guidelines". When asked if she had made observations in the ICU, she stated, "No, I have not seen it".
VIOLATION: IC PROFESSIONAL DOCUMENTATION Tag No: A0773
Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to ensure documention of infection control rounds.

Finding:

On 7/29/2020, the Division of Licensing and Certification was made aware of an outbreak of COVID-19 at the hospital. An on-site investigation was initiated.

Based on observations on 7/29/2020 and 7/30/2020, surveyors determined the hospital failed to implement all possible strategies to prevent and control the transmission of COVID-19 and that the hospital failed to ensure a clean and sanitary environment. Please see A-0749 and A-0750 for details.

On 7/29/2020 at 9:35 AM, the System Director of Infection Prevention stated, the hospital had four (4) patients who were COVID-19 positive, one (1) patient who was a person under investigation, and an outbreak of twelve (12) staff members who were COVID-19 positive.

On 7/30/2020 at 10:45 AM, the System Director of Infection Prevention was interviewed in relation to infection control surveillance. She stated, "Infection Preventionist Staff make daily rounds, I am in Administration, to monitor/enforce compliance and report back to the Unit Managers for employee follow-up. There is no documentation for the daily rounds".