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DOH Provides Information on Infection Prevention Audits in Nursing Home Association Meeting

In a meeting with nursing home associations on Feb. 14, 2024, the Department of Health (DOH) shared information about common omissions in infection prevention audits and top survey deficiencies.

Infection Prevention Audits

DOH provided some updates on the infection prevention desk audits initiated in January. Most notably, Department staff indicated that homes may submit their infection prevention audit survey tools in advance of being selected for an audit. Accordingly, nursing homes may submit the survey tool when they have some down time to prepare and submit the survey, prior to being notified that they have been selected for an audit. DOH also noted that Transitional Care Units (TCUs) in hospitals will be required to submit the infection prevention audit surveys. In addition, DOH highlighted some commonly missed items in the audits:

  • Some facilities do not have invoices for the personal protective equipment (PPE) they have purchased over the last 12 months. DOH will waive the submission of invoices if necessary.
  • DOH reminded facilities to be mindful of expiration dates on PPE supplies (e.g., masks, hand sanitizers).
  • Facilities should include in their infection prevention plans policies and procedures for limiting the staff who rotate into and out of areas where there is an outbreak of respiratory virus, where feasible and applicable.
  • DOH noted that many facilities are submitting lengthy policy manuals and asked facilities to try to submit only the infection prevention and control plans as requested.
  • Line lists should include symptom monitoring. Facilities seeking government-approved line lists may consider reviewing the DOH line list forms here and the Centers for Disease Control and Prevention's (CDC) Long-Term Care Respiratory Surveillance Line List here.

Top Survey Deficiencies

DOH also highlighted the top 10 survey deficiencies in the last quarter:

  • F812 – Food procurement, storage, preparation, distribution, and service. DOH recommended continuously auditing dietary services.
  • F880 – Infection control. DOH highlighted handwashing and staff exiting rooms with gloves on.
  • F584 – Safe, clean, comfortable, homelike environment. DOH noted that these deficiencies can quickly become widespread and mentioned dirty over-bed tables and cracked blinds. They recommended frequent room rounds.
  • F761 – Labeling drugs and biologicals.
  • F609 – Reporting of alleged violations.
  • F689 – Free of accidents and hazards; supervision and assistive devices. DOH emphasized care planning and implementation of care plans.
  • F610 – In response to allegation of abuse, neglect, investigate and correct alleged violation.
  • F684 – Quality of care.
  • F686 – Pressure ulcers.
  • F695 – Respiratory tracheostomy care and tracheal suctioning.

DOH staff also mentioned provision of CPR in accordance with medical orders and advance directives. This was not a top 10 deficiency, but was relatively frequent. DOH staff urged facilities to ensure that they have appropriate policies in place and that staff are trained to know what to do in an emergency. They noted that agency staff may not remember the facility's policies and procedures if they are rotating through various facilities for short periods.

DOH staff also pointed to resources available from IPRO, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Organization (QIO). The QIO has a "micro learning site" with resources on vaccination and other topics. More information about the IPRO QIO and the resources it provides is available here.

Contact: Karen Lipson, klipson@leadingageny.org