Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 673075 (X3) Date Survey Completed 10/13/2021
Name of Provider or Supplier Pam Health Rehabilitation Hospital Of El Paso Street Address, City, State 1600 E Cliff Dr, El Paso, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000 The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An entrance conference was held with the facility chief executive officer on the morning of 10/12/21. The purpose and process of the complaint survey were discussed, and an opportunity given for questions. An exit conference was held with the facility chief executive officer and quality director on the afternoon of 10/13/21. Preliminary findings of the complaint survey were discussed, and an opportunity given for questions. Based on the findings of the survey, the facility was non-compliant with the Condition of Participation, 42 CFR 482.42, for Infection Control. Upon surveyor entrance at the facility on 10/12/21, at approximately 8:40 a.m., no individual at the visitor/reception desk, along with erratically functioning covid-19 screening equipment, posed an Immediate Jeopardy to patients, visitors, and staff due to the potential for transmission of the virus. A plan to abate the Immediate Jeopardy was submitted by the facility on 10/14/21 at 1:13 p.m. The Immediate Jeopardy was removed but the deficient practice continued at the condition level. The facility abatement plan included the following: " ...d. A trained staff member was assigned to the visitor desk to screen staff and visitors per CDC guidelines. e. Cobalt El Paso leadership team walked the facility to ensure that visitors complied with CDC COVID-19 regulations, all visitors and staff were found to comply with the guidelines. f. COVID-19 Admission Attestation with CDC education provided to all patients present in the building. g. A written staff schedule was created and implemented for visitor desk screening for coverage during visiting hours and change of shift. h. In-service initiated 10/12/2021 to educate staff of current CDC guidelines and patient visitation screening procedures. i. Staff who will be screening visitors and staff were provided with a competency on the use of the screening equipment and form completion. j. Provided documentation of provided education to staff quarterly starting February 2021, May 2021, and October 2021. Education is provided on employee orientation as well. (Surveyor Note: Please see conflicting statements provided in staff interviews.) k. Staff are being educated prior to starting their shift, including PRN staff. l. It is expected that 100% of staff compliance with training will occur on or before October 16, 2021. m. Daily, the Chief Quality Officer, or her designee, will review the screening sheets and logs for completeness and compliance. This information will be brought forward to the Quality Committee, Medical Executive Committee, and Governing Board, quarterly and then as recommended, from those committees once compliance is met ..."
A0747 INFECTION PREVENTION CONTROL ABX STEWARDSHIP
CFR(s): 482.42

The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program.


This CONDITION is not met as evidenced by:
Based on observation, interviews, and review of facility documentation, Cobalt Rehabilitation Hospital El Paso failed to meet the Condition of Participation for Infection Control as they failed to follow current professional infection control standards for healthcare facilities related to covid-19 as set forth by the CDC (Centers for Disease Control & Prevention). This was evidenced by not following current CDC guidelines for screening procedures for recent exposure to or symptoms of covid-19 for all visitors to the hospital (refer to A0748). These failed practices resulted in the potential for exposing a vulnerable patient population, as well as all staff and visitors, to a potentially deadly disease.
A0748 INFECTION CONTROL PROFESSIONAL
CFR(s): 482.42(a)

Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership;


This STANDARD is not met as evidenced by:
Based on a review of facility documentation, observation, and staff interviews, the facility failed to ensure that an individual with adequate training or experience in infection prevention and control was responsible for implementing and monitoring the facility compliance with current CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus 2019 (COVID-19) Pandemic." This had the potential to impact the health and safety of all patients, visitors, and staff at the hospital. Findings were: Facility policy #7012021 entitled "Infection Control Plan" included the following: The policy included the following: " ...The Infection Control Practitioner (ICP) is at least a part time position in which the ICP is qualified through education, training, experience, and/or certification or licensure. In the absence of sufficient expertise, the Hospital ICP may consult via a member of the Medical Staff with such expertise and/or the use of consultations with other ICPs. This person has the responsibility for the daily management of infection prevention and control activities ... C. Activities to minimize, reduce or eliminate risk of infection 1. Education ... d. Additional education of the patients, staff, LIP/AHP, contracted staff, and volunteers, if any, will occur based on identified needs of the Hospital ..." Facility policy #8856532 entitled "Interim Infection Prevention and Control Recommendations For Healthcare Personnel During The Coronavirus Disease," effective date 11/2020, included the following: "Purpose To provide the source of guidance for the hospital during the Coronavirus Disease 2019 (COVID-19) Pandemic. Background This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. As healthcare facilities begin to relax restrictions on healthcare services provided to patients, in accordance with guidance from local and state officials, there are precautions that should remain in place as a part of the ongoing response to the COVID-19 pandemic. Policy The hospital utilizes the CDC [website address given]..." The most current CDC covid-19 guidelines that the facility had in their infection control documentation notebook was dated November 2020. In an interview with Staff #3, Chief Clinical Officer, on 10/12/21 at 11:45 a.m., she stated, "We don't take patients with active covid ..." When asked about whether she was training nursing staff on Covid-19 issues and updates, Staff #3 stated, "I haven't done any training on paper. If I see someone not using the right PPE, I'll catch them and say, 'You need to put on a mask,' or 'You need to put on whatever.' When Covid first hit, [another staff person] was here and she did training. She was here still at the beginning of 2021 ... Otherwise, I rely on [Staff #4] (Infection Control Director) to do that for me ..." In an interview with Staff #4, Director of Quality/Infection Control/Employee Health, on 10/12/21 at 10:55 a.m., when asked what training she had in infection control issues, she answered, "I've done some online training." When asked if it was beyond what all other employees received, Staff #4 stated, "No. It's the same ..." When asked if she was training staff in infection control issues, and specifically Covid-19 issues/updates, she stated, "No, the nursing director (Chief Clinical Officer, Staff #3) is doing that for all the nursing staff working on the floor. I haven't done any training ..." When asked who was keeping up with current CDC guidelines and recommendations, she said, "I do that with... the Director of Plant Operations ... We're a Covid-free hospital. A patient has to test negative before they can come here ..." When surveyor stated the most recent guidelines she could find that the facility was following were from November 2020, Staff #4 agreed this was the case. In an interview with Staff #1, hospital CEO, on 10/12/21 at 11:10 a.m., he stated, "[Staff #4] is our infection control person ... We also get a lot of direction from corporate ...They're located in Garland, Texas ..." When surveyor mentioned that the most recent CDC guidelines the hospital had were from November 2020, he said, "But I get the latest area information in meetings I'm involved with locally. I find out about our current surge numbers. I also sit in on regular calls with the RAC (regional advisory council) ..." A review of the personnel file of Staff #4, Quality Director/Infection Control Director/Employee Health, revealed no specialized training in infection control beyond that received by all hospital staff. Her file included a signed job description and annual required training of all staff. While on-site, the surveyor requested the job description for her position as Infection Control Director, rather than Quality Director. The only job description provided was entitled "Chief Quality Officer." The surveyor again requested a job description for the Infection Control position via off-site email on 10/14/21. The email reply again included only the job description for "Chief Quality Officer." The only infection control section of this description included the following check-offs: "- Complies with P&Ps relating to infection control for self, patients, visitors, and coworkers ... - Adheres to hand hygiene P&Ps ... - Adheres to Universal Precautions ..." Upon entry to the facility on the morning of 10/12/21, this surveyor was not screened for symptoms related to Covid-19. There was a thermometer at the front for self-screening which did not give a reading -- only an "error" message. On the visitor/reception desk was a clipboard with a visitor sign-in sheet. This included blank lines on which a visitor could print their name. No individual was at the front reception desk on the first floor to provide assistance or clarification of the entry procedure. In fact, the hospital's entire first floor appeared completely empty. This surveyor circled through the first floor which included staff offices, vacant patient rooms and a dining area and kitchen. When running water was heard, surveyor followed the sound to the kitchen where an individual was washing dishes. He escorted surveyor to the hospital's 2nd floor administrative offices. The only options for a potentially unscreened visitor was to go to the 2nd floor to attempt entry into the locked administrative offices, or go directly to the patient unit on the 2nd floor which had current inpatients. Upon a subsequent tour of the same entry area on the afternoon of 10/12/21 with the hospital CEO, he stated there was a self-screening questionnaire at the top of the sign-in sheet. The questionnaire was in small print and only half-visible under the clip board clasp. The information it contained was not congruent with current CDC guidelines. Upon entry to the facility on the morning of 10/13/21, an individual had been assigned to be at the front reception desk. Surveyor again attempted to use the thermometer that was supplied for self-assessment. The reading was 93.6 degrees Fahrenheit. No additional temperature check was requested or required by staff present.
E0000 An entrance conference was held with the facility chief executive officer on the morning of 10/12/21. The purpose and process of the complaint survey were discussed, and an opportunity given for questions. Complaint #TX00384355 was found unsubstantiated with no deficiencies cited regarding emergency preparedness. An exit conference was held with the facility chief executive officer and quality director on the afternoon of 10/13/21. Preliminary findings of the complaint survey were discussed, and an opportunity given for questions.