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 01G011 (X3) Date Survey Completed 03/19/2021
Name of Provider or Supplier Rainbow Omega, Inc, Street Address, City, State 202 Hope Drive, Eastaboga, AL
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)
W0341 NURSING SERVICES
CFR(s): 483.460(c)(5)(ii)

Nursing services must include implementing with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to control of communicable diseases and infections, including the instruction of other personnel imethods of infection control.


This STANDARD is not met as evidenced by:
Based on observation, interview, and policy review, the facility failed to follow their agency's Infection Control Policy regarding the screening for COVID prior to the start of the employee's shift for one of one employee identifier (EI) #3. The COVID screening consisted of answering a questionnaire, checking the employee's temperature and signing the questionnaire. The employee failed to perform hand hygiene. This deficient practice had the potential to affect all 14 of 14 clients at the agency.

Findings include:

Review of the agency's policy titled, "Infection Control and Universal Precautions" updated 03/16/21 indicated, "To prevent the possible spread of infections and communicable diseases, all staff are to be trained on techniques for universal precautions and preventing cross-contamination and will be required to follow the established procedures ...Screening protocol ...All employees will be screened before beginning their job responsibilities by ...answering a questionnaire concerning any possible exposure to the named disease or virus. Checking temperature and recording result on questionnaire. Signing questionnaire ...the importance of proper hand hygiene and proper handwashing techniques."

Observation on 03/17/21 at 5:59 AM, EI #3/ Resident Aide (RA) arrived at the facility, picked up a disposable mask from the screening station located on a table on the right side of the main entrance and put it on as she passed quickly through the common area down a hallway. EI #3 did not sanitize her hands, complete the screening questions sheet available on at the screening station and did not take and record her temperature.

Continued observation on 03/17/21 at 6:05 AM revealed EI #3 carried a large bundle of laundry down the center hallway, passed clients as she moved to the end of the hallway and deposited the bundle outside for pickup. On 03/17/21 at 6:11 AM, EI #3 returned to the screening station where she sanitized her hands, checked her temperature, and filled out the screening form reviewing exposure to others with known or suspected COVID-19.

During an interview on 03/17/21 at 6:14 AM, EI #3 verified that she did not check her temperature, sanitize her hands, and complete the screening questions sheet when she entered the facility. She explained she "just forgot," because she was rushing to get clocked in by 6:00 a.m. when her shift began. She said she had been trained on the requirement to be responsible for self-screening every time she comes into the building."

During an interview on 03/17/21 at 6:25 AM, EI #4, Licensed Practical Nurse (LPN), who also served as the Team Leader for the Resident Aide staff, verified that all staff had been trained and were aware of the requirement to complete the steps at the screening station before proceeding further throughout the residence. EI #4 confirmed it was not an acceptable practice for staff to proceed into the building without completing screening.

During an interview on 03/17/21 at 9:55 AM, EI #1, Director of Nursing/Registered Nurse (DON) confirmed that all staff, including EI #3 received training on the screening process for staff to complete upon arrival in the building for their shifts. She added staff compliance was monitored by the nursing staff, including herself, however staff were expected to be responsible to engage in all infection control practices.

Review of EI #3's training records revealed, "Acknowledgment of Training on Infection Control and Universal Precautions Policy and Procedures" including the statement, "I acknowledge that I have received Rainbow Omega's policy and procedures on Infection Control and Universal Precautions and was trained on this policy and procedure and I understand and agree to abide by this policy and procedure." The training records documented EI #3 had been most recently trained and signed the acknowledgment documents on 11/09/20 and 03/05/21.