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Based on observation, interviews, and record review, Mesa Hills Specialty Hospital failed to meet the Condition of Participation for Governing Body as evidenced by failing to:

* Conduct a risk analysis to address potential dangers of initiating an essentially commercial laboratory which planned to conduct COVID-19 and respiratory panel testing. The testing laboratory was a small room opening onto the hospital central supply room. This had the potential of exposing patients, staff and visitors to deadly viruses. In addition, the hospital failed to ensure a safe site for COVID-19 testing of staff as the testing was conducted in the office of the infection preventionist with possible generation of lab waste. The facility had made no assessment of the potential dangers these practices posed for all patients and staff of the facility via possible aerosolizing of pathogens or biohazard contamination, among other routes, and no documented evidence was provided to surveyors that the hospital's governing body had approved the plan. (refer to A0749).

* Provide specialized training to the Infection Preventionist beyond the regular infection control training received by all staff. This had the potential of endangering all staff and patients due to poor infection control practices and oversight as a nurse with no specialized training was in charge of the infection control program for a long-term acute care hospital in which numerous patients had multiple co-morbidities and were immunocompromised. (refer to A0748).

* Ensure a fully functional and operating Infection Control Program as the untrained Infection Preventionist was left with no guidance to develop policies and procedures related to COVID-19, as well as other infection control issues. She had developed and implemented policies with no oversight or approval of the hospital's governing body because the governing body had not addressed such a policy themselves, despite a current global viral pandemic. In addition, there were no infection control meeting minutes available for surveyor review, and a review of minutes of QAPI and medical executive committee meetings in 2020 revealed no discussion of infection control issues beyond indicator data that is required to be collected by all hospitals. (refer to A0749).

* Ensure physical modifications made to the hospital building were overseen in a manner which did not generate potential cross-contamination issues. (refer to A0749).

* Provide appropriate oversight of hospital contracted services as there were infection control issues with the in-facility contracted dialysis provider. (refer to A084).

These failed practices potentially resulted in seven (7) previously negative patients becoming positive for COVID-19 while in the facility, as well as 95% of the staff becoming positive for COVID-19. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Governing Body.

Based on observations, interviews, and record reviews, the facility failed to provide an effective Infection Control Program to prevent Hospital Acquired Infections when:

* Staff were not Fit Tested for non-rebreather masks, as the CDC recommends.(A0749)

* Staff suspected of having Covid-19 were being tested on the patient floor.

* Seven (7) previously negative patients became positive for Covid-19 while in the facility.

* 95% of the staff became positive for Covid-19.

* The facility's contracted Dialysis provider was not providing services in a sanitary manner to prevent cross-contamination. (refer to A0749)

* The hospital failed to conduct a risk analysis to address potential dangers of initiating an essentially commercial laboratory which planned to conduct COVID-19 and respiratory panel testing. The testing laboratory was a small room opening onto the hospital central supply room. This had the potential of exposing patients, staff and visitors to deadly viruses. (refer to A0749).

* No specialized training was noted for the Infection Preventionist beyond the regular infection control training received by all staff. This had the potential of endangering all staff and patients due to poor infection control practices and oversight as a nurse with no specialized training was in charge of the infection control program for a long-term acute care hospital in which numerous patients had multiple co-morbidities and were immunocompromised. (refer to A0748).

* There was no fully functional and operating Infection Control Program as the untrained Infection Preventionist was left with no guidance to develop policies and procedures related to COVID-19, as well as other infection control issues. She had developed and implemented policies with no oversight or approval of the hospital's governing body because the governing body had not addressed such a policy themselves, despite a current global viral pandemic.

* No infection control meeting minutes were available for surveyor review and a review of minutes of QAPI and medical executive committee meetings in 2020 revealed no discussion of infection control issues beyond indicator data that is required to be collected by all hospitals. (refer to A0749).

* Physical modifications made to the hospital building were not overseen in a manner which ensured that potential cross-contamination issues were not generated. (refer to A0749).

These failed practices potentially resulted in seven (7) previously negative patients becoming positive for COVID-19 while in the facility, as well as 95% of the staff becoming positive for COVID-19. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Infection Control.

Based on observations, interviews, and record reviews, the facility failed to train and monitor contracted providers when,

The facility's contracted services for Dialysis and Radiology were not properly cleaning their equipment and adhering to the facility's infection control policies.

An observation the morning of 9/21/20, revealed a portable x-ray machine being wheeled into the facility. The machine had a thick dust build-up and the wheels had debris stuck on the treads.

During an interview on 9/21/20, the x-ray technician stated, "I clean the machine off after each use ...It must be dust." When asked what other types of facilities the technician enters, he stated, "I go to nursing homes too."

When asked if the facility had trained him on infection prevention, the technician reported no, he is contracted, his company trains him.

During an interview on 9/22/20, Staff #18, Infection Control Director reported she was not aware of the dirty equipment being brought in and confirmed it would present an infection control concern.

An observation on the morning of 9/21/20, revealed Staff #6, US Renal Care, RN, working in a patient's room 512, Staff #6 removed his gloves, but did not wash his hands. Staff #6 proceeded to leave the room wearing his disposable apron. Staff #6 walked down the hall and entered another patient's room; the gown was removed in the second patient's room. He did not wash or sanitize his hands prior to touching the second dialysis machine.

During an interview on 9/21/20, when asked if he had received infection control training from the facility, Staff #6, US Renal Care nurse stated, "No, I was trained by US Renal. I am contracted with the facility to do dialysis."

An observation on the morning of 9/22/20 revealed the Dialysis machine in the dialysis room. The machine had brown drips running down the side. The top of the machine had residue rings where something had been sitting on top of the machine.

During an interview on 9/22/20, Staff #6, US Renal nurse stated, "That must be coke." Staff #6 confirmed the dirty machine had been sitting overnight in the dialysis clean supplies storage room.

An observation on the morning of 9/23/20, revealed Staff #6, US Renal nurse, sitting at the nursing station wearing a disposable gown.

During an interview on 9/23/20, Staff #18, Infection Control Director confirmed the finding and reported the Renal Technician was supposed to remove his PPE before leaving the room. Staff #18 confirmed the facility did not include the contracted staff in its infection control trainings.

Based on a review of facility documentation and staff interview, the facility failed to ensure medical records were authenticated and completed within the timeframe specified by hospital policy and current standards of medical practice for 6 of 8 patient records reviewed for completion.

Findings were:

Facility policy #IM.01.01.01 entitled "Monitoring Incomplete Delinquent Medical Records - Physician Letters," last reviewed 5/20, included the following:

" ...To assure the timely completion of health information (medical records) to support on-going patient care and regulatory compliance. The timeframe for completion is specified as 30 days from the date of discharge per Medical Staff Rules and Regulations and The Joint Commission standards ..."

A total of eight (8) patient records [Patients #1-8] were reviewed for completed documentation. Of these, six (6) records [Patients #1, 4-8] included numerous documents not authenticated by the documenting physician which were well past the 30-day timeframe specified by the hospital. For example, the record of Patient #5 included approximately 50 unauthorized physician progress notes dating as far back as 5/19/20.

On the afternoon of 9/22/20 in the office of the infection control nurse, the health information management staff member dropping off the records for review stated, "Obviously, these have a few issues."

Based on a review of facility documentation and staff interview, the facility failed to ensure the individual in charge of infection control at the hospital was qualified through education, training, experience or certification in infection control.

Findings:

No facility policy could be located which addressed the required training or background of the hospital Infection Preventionist (IP).

A review of the IP's personnel record revealed no additional training. In addition, no evidence was located which indicated she had been appointed by recommendations of the medical staff or nursing leadership.

In an interview with Staff #18, the hospital infection control nurse/infection preventionist, on the afternoon of 9/22/20 in her office, she stated she was an LVN and had received no specialized or advanced training for her role as IP beyond the basic infection control training received by all staff. She also stated she was unaware of any future plans for her training. Regarding her pandemic/Covid-19 training, she stated, "We attended a city training back in March, so we kind of came back and shared with everyone what we knew. But that was it."

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure a functioning infection prevention and control program which included surveillance and prevention, as well as a clean and sanitary environment, to avoid sources and transmission of infection and communicable diseases by failing to:

1) Provide evidence of a functioning infection control program, with documented evidence of having current policies and procedures related to COVID-19.

2) Ensure the safety of all patients and staff as COVID-19 testing was performed in a room off the clean central supply room and in the office of the infection prevention nurse. No risk analysis was performed to ensure these locations were safe locations to perform such testing thus mitigating possible cross-contamination.

3) Carefully consider and document infection control issues associated with physical modifications made to a wound care clinic housed inside the hospital.

4) Provide documented evidence of involvement of medical, nursing, laboratory, housekeeping, and wound care staff in discussion of infection control issues currently affecting the hospital.

5) There was no Isolation sign on a patient requiring Contact Isolation, enabling someone to enter the room without the proper PPE. (Patient #17)

6) Environmental Staff (EVS) were not provided Covid-19 testing and N95 fit testing, making it possible for them to spread airborne viruses. (Staffs #4 and #7)

7) The facility's contracted services for Dialysis and Radiology were not properly cleaning their equipment and adhering to the facility's infection control policies.

8) (3) Three staff work chairs were torn and uncleanable, creating an environment for cross contamination.


Findings:

Mesa Hills Specialty Hospital is a long-term acute care hospital with patients who have multiple co-morbidities. Thus, the patients there are extremely ill and many are immunocompromised by one or more chronic health issues.

1) Failed to provide evidence of a functioning infection control program, with documented evidence of having current policies and procedures related to COVID-19.

Facility policy entitled "Infection Prevention and Control Plan 2019," last revised 2/2019, included the following:

"15 ... Activities include but are not limited to: direct patient and staff flow, communicate with administration, medical staff, department managers, employees and the local health and law enforcement department as appropriate. Ensure adequate supplies for patients and staff. Determine who will be restricted from entering or leaving the facility. Admissions, discharges and transfers may be halted or delayed as well as temporarily stopping services. Coordinate with the plant operations activities to ensure proper implementation of Environment of Care safety plans as well as the bioterrorism plan to contain the spread of the infection. The IP will have the primary responsibility to direct activities in concert with the Infectious Disease Physician, the Administrator and the host facility. The IP is the primary contact when this type of infection has been introduced into the facility. These activities may be expanded or extended for a prolonged period.

16. The Infection Preventionist will attend planned education meeting with the local APIC Chapter, and District Bioterrorism Planning events ...

18. The Infection Preventionist will facilitate the monitoring of the effectiveness of the prevention and/or control activities and interventions ...

19. The Infection Preventionist will gather data monthly and disseminate information gathered and analyzed to the licensed independent practitioners and staff as it applies to patient care processes ...

20. The effectiveness of the Infection Prevention and Control Plan will be evaluated at least annually to ensure the adequate systems to access information, laboratory support is provided. and adequate equipment and supplies are provided to support infection prevention and control activities ...

21. The Infection Prevention and Control Committee will meet at least every other month. The committee will report to QAPI, the Medical Executive Committee and then upwards to the Governing Board ..."


In an interview with Staff #18, hospital infection preventionist, on the morning of 9/22/20, she reported the hospital had no real policy on how to deal with the Covid-19 pandemic. "I wrote something up in March - it was on 3/4/20. It was never officially approved ...I never got any other guidance from our corporate office. Then I ended up revising it some in June." Staff #18 originally reported she believed her policy had been approved by the hospital QAPI committee at the June meeting, held 6/15/20. However, she reported having revised her policy on 6/17/20. When asked about the membership of that committee, she admitted there was no member of the medical staff on the committee. "I changed some more stuff on there - but there hasn't been any approval by anyone..."


Facility document entitled "COVID-19 Pandemic," dated 3/2020 was identified as the policy written by Staff #18. The document included information about contact, droplet and airborne precautions. The 3/2020 version of the document did not prohibit visitors to the hospital, and simply required the visitors be "limited to those necessary for the patient's well-being and care and should be advised about the possible risk of acquiring infection ..." Staff #18 had attached some items "from the Internet" to the policy she wrote. One item was about the optimization of PPE (personal protective equipment) during shortages. Another was a document entitled, "COVID-19 Focused Infection Control Survey for Acute & Continuing Care" which appeared to be based on a CMS focused infection control survey for Covid-19 issues, but had been labeled as having been prepared by the Joint Commission. The only other attachments were several signs to be posted at the facility involving how to screen visitors for entry. When asked about staff training on Covid-19, she stated, "I emailed this information and the policy out to our staff. They had to acknowledge that they had received it."


A review of the IP's personnel record revealed she was an LVN with no specialized training in infection control. In addition, no evidence was located which indicated she had been appointed by recommendations of the medical staff or nursing leadership.


In an interview with the hospital infection control nurse/infection preventionist on the afternoon of 9/22/20 in her office, she confirmed she had received no specialized or advanced training for her role as IP beyond the basic infection control training received by all staff. She also reported she was unaware of any future plans for her training. Regarding her pandemic/Covid-19 training, she stated, "We attended a city training back in March, so we kind of came back and shared with everyone what we knew. But that was it."


2) Failed to ensure the safety of all patients and staff as COVID-19 testing was performed in a room off the clean central supply room and in the office of the infection prevention nurse. No risk analysis was performed to ensure these locations were safe locations to perform such testing thus mitigating possible cross-contamination.

During a tour of the hospital on the morning of 9/22/20, Staff #1, the hospital administrator, and Staff #22, respiratory therapist, guided surveyors to a small room off the central supply room of the hospital. The central supply was the area where clean patient supplies and equipment were stored as well as new staff PPE. Staff #22 explained that the facility had decided to start its own testing lab for COVID-19 "and other respiratory viruses as well." She provided a listing of 18 items a respiratory panel tested for, including several coronaviruses, influenza, and mycoplasma pneumoniae. She added that it had been decided they would also provide testing services for healthcare entities outside their own hospital. The administrator discussed how pleased a pulmonology group had been to hear that the hospital could provide their group with testing. Staff #1, the administrator, stated, "They have 5 locations around El Paso ... I'm not sure who decided this would be a good idea [referring to the lab] ... We just got word we'd be doing this ..."


In an interview with the infection prevention nurse on the morning of 9/22/20, she reported initially, she had tested staff for COVID-19 in her own office. She reported the test was packaged appropriately and the equipment used had been bagged and removed in a biohazard bag. However, when asked if a staff member had sneezed or used a tissue during the test, she admitted that the tissue "would have just been thrown in my trash here." Six (6) of the staff members she tested in her office had been positive for COVID-19. In addition, she admitted that any refrigeration required during the testing would have been done in her own small office refrigerator. When asked if a risk analysis had been completed per CDC guidelines for establishing an appropriate location to test within the hospital, she reported there had been no such analysis. She added there had not even been discussion on appropriate locations within the hospital for testing. She also said, "maybe there's a better place in the hospital for the lab than a place where they have to carry biohazard bags through our clean supply room." As the name suggests, the clean supply room stores clean, unused patient supplies.


In a document entitled "Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19)," by the CDC (available at: https://www.cdc.gov/coronavirus/2019-ncov/lab/lab-biosafety-guidelines.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Flab-biosafety-guidelines.html), they included the following:

" ...All laboratories should perform a site-specific and activity-specific risk assessment to identify and mitigate risks. Risk assessments and mitigation measures are dependent on:

* The procedures performed

* Identification of the hazards involved in the process and/or procedures

* The competency level of the personnel who perform the procedures

* The laboratory equipment and facility

* The resources available

Follow Standard Precautions when handling clinical specimens, all of which may contain potentially infectious materials.
Follow routine laboratory practices and procedures for decontamination of work surfaces and management of laboratory waste ..."

The infection prevention nurse did report that more recently she was testing staff members in their cars rather than in her office. However, the fact that initial testing was performed in her office and that the hospital was now setting up, in essence, a commercial laboratory and bringing in specimens from other facilities for COVID-19 testing, yet there had been little or no discussion of whether the locations were carefully considered and/or approved with medical staff, governing body and/or lab director involvement, would indicate little or no consideration of potential infection control risks or concerns on the part of hospital. In fact, Staff #18, the infection preventionist, reported she had been out much of July, 2020, when the decision was made by an unknown individual to start up the small lab area off the central supply room. Again, Mesa Hills Specialty Hospital served patients with multiple co-morbidities in probable immunocompromised condition.

In a telephone interview with Staff #26, corporate medical director of the hospital working for the managing company Beyond Health in Denton, Texas, on the morning of 9/23/20 at approximately 9:45 a.m., he stated, "I had no idea that the hospital was going to operate a commercial laboratory in it ... Completely unaware ... Don't know who would have decided that ..."


3) Failed to carefully consider and document addressing the infection control issues associated with physical modifications made to a wound care clinic housed inside the hospital.

In an interview with Staff #1, hospital administrator, on the afternoon of 9/22/20 in the office of the infection prevention nurse, he reported physical modifications of an area called "Pulse," a wound care clinic located off the main hallway of the hospital, had occurred in March 2020. He revealed he had not reported the modifications to the state as required by regulations. In separate interviews with Staff #1, the administrator, and Staff #18, the infection prevention nurse, on the afternoon of 9/22/20 in the office of Staff #18, they both stated that a risk analysis of the potential infection control impact of the modifications had not been considered. The hospital administrator did state they had used a firm that was familiar with working at healthcare locations and that this company had put up plastic sheeting around the area. However, there are multiple infection control considerations and risks when physical modification or construction occurs at a hospital. He stated, "They really just removed a couple of walls in there ... We got interim guidance on what to do. We developed a team in March. We had a meeting with the leadership to tell them what we were going to do. When I spoke to corporate, I just really didn't get any response."

A summary of such risks available from APIC (the Association of Professional in Infection Control & Epidemiology), entitled "Infection Control Risk Assessment: Matrix of Precautions for Construction & Renovation," (available at http://apic.org/Resource_/TinyMceFileManager/Education/EPI_Intensive/Resourse_Documents/ICRA_Matrix.pdf), addressed the numerous infection control issues which the modification of an existing healthcare facility can generate, and included the following:

"Using the following table, identify the Type of Construction Project Activity (Type A-D) ...

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies includes, but not limited to:

* sanding of walls for painting or wall covering

* removal of floor coverings, ceiling tiles and casework

* new wall construction

* minor duct work or electrical work above ceilings

* major cabling activities

* any activity which cannot be completed within a single workshift ...

Step Two:

Using the following table, identify the Patient Risk Groups that will be affected.

If more than one risk group will be affected, select the higher risk group: ...

Highest Risk ...
Any area caring for immunocompromised patients ..."

Given the steps above, the following would be recommended by APIC guidelines as Class III construction for infection control measures:

"During Construction Project: ...

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site
with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid ...

Upon Completion of Project: ...

1. Do not remove barriers from work area until completed project is inspected by the owner's Safety Department and Infection Control Department and thoroughly cleaned by the owner's Environmental Services Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with disinfectant.

5. Remove isolation of HVAC system in areas where work is being performed.


During a tour of the wound care clinic, housed within the hallway of the hospital, on the afternoon of 9/22/20 with Staff #25, Plant Ops Manager, he was asked about the March 2020 modification of the area. He reported he had not been in his position at the time, but that the Frigidaire air re-circulators/conditioners were separate units and in each room of the hospital. He said he didn't believe the air from the wound care area would carry into the hospital, stating, "The chances aren't very high .... These (Frigidaire individual units) just recirculate the air. It's just recirculating and recirculating." However, the wound care clinic was simply another room off the main corridor of the hospital. The door to the clinic was found open to the main hallway during the tour. Patient rooms also opened onto this hallway. Staff #25 also stated that when the construction project was going on, the hospital had no one filling the position of Plant Ops Manager.

Again, no individual working at the facility appeared to have been aware of potential risks of the modifications, and thus, relied solely on the contract service completing the work. It was unknown whether or not appropriate steps had been taken to address the infection control risks.


4) Failed to provide documented evidence of involvement of medical, nursing, laboratory, housekeeping, and wound care staff in discussion of infection control issues currently affecting the hospital.

In an interview with Staff #18, infection prevention nurse, on the afternoon of 9/22/20 in her office, she reported the infection control committee met separately from the hospital QAPI committee. When minutes of meetings were requested, she stated, "I have the notes. I just don't have them written up." She admitted the minutes had not been "written up" since February, 2020. On the morning of 9/23/20, QAPI minutes were available for surveyor review for meetings held on 6/15/20 and 7/23/20. Neither set of minutes included documented discussion of infection control topics. In addition, meeting minutes of the QAPI committee were reviewed for 2/17/20. There was no documented discussion of infection control issues. These were the only QAPI minutes available for surveyor review. No infection control minutes were made available. It had been reported previously that the 6/15/20 QAPI meeting was the one in which the COVID-19 policy written by the infection prevention nurse had been approved by the committee. This was not reflected in the minutes. In addition, after the IP nurse had revised the policy, the revisions were supposedly reviewed in the 7/23/20 meeting. Staff #18 stated, "I think in July we went over that revision ... All of that discussion would have been verbal. It wouldn't be in the minutes."

Medical Executive Committee (MEC) Meeting Minutes from 1/16/20 were the last minutes available for the MEC. An agenda of an April 2020 meeting was provided for surveyor review, but there was no documented evidence of discussion of any specific topic. Adoption of COVID-19 policies was not a topic listed on the agenda.


5) There was no Isolation sign on a patient requiring Contact Isolation, enabling someone to enter the room without the proper PPE. (Patient #17)

An observation on the morning of 9/21/20, on the patient unit, revealed Patient room #9 with a supplies cabinet hanging on the door. Staff #4, EVS at the nursing station, asked the monitor tech for a Contact Isolation Precautions sign. Staff #4 stated, "Number 9 doesn't have this."

During an interview on 9/21/20, when asked how he knew the patient required isolation, Staff #5 stated, "I saw the isolation box and assumed it was Contact by the equipment on the door." When asked who was responsible for deciding what type of isolation is needed, Staff #4 stated, "The nurse is supposed to."

Review of the patient in room #9's medical record reflected Patient #17 had a Physician's order for Contact Isolation for ESBL (a drug resistant bacteria) of the urine.

Review of the facility provided Isolation Precautions (Effective date 4/1/10) reflected, " ...General Procedures for all isolation A. An isolation sign must be posted beside the door frame ..."


6) Environmental Staff (EVS) were not provided Covid-19 testing and N95 fit testing, making it possible for them to spread airborne viruses. (Staffs #4 and #7)

During an interview on the morning of 9/21/20, when asked about the training for Covid-19 prevention, Staff #4, EVS stated, "I haven't really gotten the training ...I wear gloves, gown, mask, and a shield...I didn't get fit-tested."

An observation on the morning of 9/21/20, on the patient unit, revealed Staff #7, EVS wearing blue gloves, carrying a trash bag into the soiled utility room. Staff #7, discarded the bag and closed the door; he did not remove his soiled gloves. Staff #7 was observed wearing the blue gloves throughout the day.

During an interview on 9/21/20, when asked if the facility had conducted the N95 fit test and the infection control training for Covid-19, Staff #7, EVS stated, "No, they told me to wear the N95 mask when I clean in Covid rooms, they checked to see if it was tight ...I had it fit tested somewhere else ...I know about the Covid from my other employer ..." When asked why he was wearing gloves, Staff #7, EVS stated, "For protection."

Staff #18 was unable to provide documentation of the infection control training provided to the staff. Staff #18 confirmed the staff are to remove their gloves and wash their hands before exiting a room or handling soiled items.

During an interview on 9/21/20, when asked if the facility conducts the N95 fit tests, Staff #18, Infection Control Director stated the CDC guidelines allows for an alternate method of testing. The staff were physically checked to see if they had a tight fit.

Review of the facility provided CDC Fit Test document (undated) reflected, " ...the seal check does not have the sensitivity and specificity to replace either fit test methods, qualitative or quantitative to replace the fit test ..."

Review of the facility provided Isolation Precautions (Effective date 4/1/10) reflected, " ...General Procedures for all isolation ...These precautions include the following:

a. Hand Hygiene -- perform hand hygiene after contact with contaminated items. Also perform hand hygiene between patients, before and after gloving or when indicated by obvious contamination.

b. Gloves --- Wear gloves (clean non sterile) [sic] when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms. Remove gloves immediately, dispose of in the appropriate container and perform hand hygiene.

c. Mask, eye protection, face shield -- These items are worn to protect the eyes, nose and mouth mucous membranes during procedures that cause spraying or aerosolization.

d. Gown, protective apparel -- Wear gowns, aprons, or other protective apparel(clean non sterile) to protect skin and clothing if contact with or splashing blood, body fluids, excretions is likely. Remove soiled apparel and dispose of appropriately, then perform hand hygiene as soon as possible ...Standard Precautions should be used for all patients receiving care, regardless of their diagnosis or presumed infection status ...standard precautions include:

2. Hand hygiene before and after patient contact, and after removing gloves or other PPE ...Organizational Factors that Affect Adherence with lnfection prevention and Control Compliance.

1. Senior Management support of safety programs.

2. Hand washing Compliance

3. Respiratory Protection Compliance

4. Having clear policies and protocols, having adequate training in infection control

procedures, and having specialists available ...

Fit testing must be conducted for all employees required to wear tight-fitting facepiece respirators as follows:

1. Prior to initial use.

2. Whenever an employee switches to a different tight-fitting facepiece respirator (for example, a different size, make, model, or style).

3. At least annually. Employers must ensure that an additional fit test is conducted if an employee experiences a change in physical condition that could affect the seal on the tight-fitting facepiece respirator..."


7) The facility's contracted services for Dialysis and Radiology were not properly cleaning their equipment and adhering to the facility's infection control policies.

An observation the morning of 9/21/20, revealed a portable x-ray machine being wheeled into the facility. The machine had a thick dust build-up and the wheels had debris stuck on the treads.

During an interview on 9/21/20, the x-ray technician stated, "I clean the machine off after each use ...It must be dust." When asked what other types of facilities the technician enters, he stated, "I go to nursing homes too."

When asked if the facility had trained him on infection prevention, the technician reported no, he is contracted, his company trains him.

During an interview on 9/22/20, Staff #18, Infection Control Director reported she was not aware of the dirty equipment being brought in and confirmed it would present an infection control concern.

An observation on the morning of 9/21/20, revealed Staff #6, US Renal Care, RN, working in a patient's room 512. Staff #6 removed his gloves, but did not wash his hands. Staff #6 proceeded to leave the room wearing his disposable apron. Staff #6 walked down the hall and entered another patient's room; the gown was removed in the second patient's room. He did not wash or sanitize his hands prior to touching the second dialysis machine.

During an interview on 9/21/20, when asked if he had received infection control training from the facility, Staff #18, US Renal Care nurse stated, "No, I was trained by US Renal. I am contracted with the facility to do dialysis."

An observation on the morning of 9/22/20 revealed the Dialysis machine in the dialysis room. The machine had brown drips running down the side of the machine. The top of the machine had residue rings where something had been sitting on top of the machine.

During an interview on 9/22/20, Staff #6, US Renal nurse stated, "That must be coke." Staff #6 confirmed the dirty machine had been sitting overnight in the dialysis clean supplies storage room.

An observation on the morning of 9/23/20, revealed Staff #6, US Renal nurse, sitting at the nursing station wearing a disposable gown.

During an interview on 9/23/20, Staff #18, Infection Control Director confirmed the finding and reported the Renal Technician was supposed to remove his PPE before leaving the room.


8) (3) Three staff work chairs were torn and uncleanable, creating an environment for cross contamination.

An observation on the morning of 9/21/20, revealed two chairs in the nurse's station and one chair in a four-bed patient room; the chairs had large areas of missing vinyl, making them unable to be sanitized.

During an interview on 9/21/20, Staff #1, Operations Administrator, confirmed the finding.







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