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)
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.