August 2021 Regulatory Updates

AS OF AUGUST 13, 2021

Infection Control surveys are still being conducted both in conjunction with complaints and annuals.  Not surprisingly, F880 citations are coming out of nearly every survey, having become the most common citation, and typically these are repeat citations.

QAPI deficiencies are being cited for IC programs that are not adequately implemented (per the below deficient practice observed) unless the facility shows they have recognized and are addressing the problems with a PIP showing evidence of progression toward compliance.  The CHCA Quality Initiatives and Leadership Committee has taken on combatting the prevalence of QAPI deficiencies as a primary objective for the coming months.

Most frequently cited deficiencies:

  • Infection Control
  • Insufficient Staffing

What’s being cited under Infection Control

  • Hand-washing vs. sanitizer – inappropriate use

CDC: Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. 

  • Sanitizer not used before/after glove use
  • Hand-washing duration inadequate
  • Hand hygiene provided to residents before meals
  • PPE worn incorrectly, especially masks – also citing for residents misuse of PPE
  • Exiting IC area without disposing of PPE
  • Distinguishing PPE use from isolation vs. quarantine, donning/doffing PPE between these spaces and between residents
  • Touching unclean to clean surfaces
  • Treating a double occupancy space as independent IC spaces – especially housekeeping changing rags, mop heads, completing one space before moving to the next
  • Social distancing of residents – permitting congregating around nurse carts/stations or permitting residents to leave quarantine areas
  • Inadequate staff screening – lack of oversight on evenings/nights/weekends
  • Staff permitted to work after indicating symptoms on screening sign-in sheet
  • Vendors permitted entry without mask use