Complaint Investigation Report

9099C(1).. LPA interviewed the Administrator on 12/2/2021, when conducting the 10-day inspection, who confirmed there were (3) positive staff cases of Covid-19 on the following days: Staff (S1) received a positive test result on 5/26/2021; staff (S2) received a positive test result on 9/7/2021; and Staff (S3) received a positive test result on 11/16/2021.

Administrator stated the positive cases were not reported to the Department or to local public health but were reported to the regional center. Administrator stated she was not aware that one positive case needed to be reported, but that only if there were two or more cases. LPA received information from ACRC that they do not have a record of any positive Covid-19 cases having been reported for 2021. LPA confirmed with local public health that per All Facilities Letter (AFL) 20-75.1 issued 7/22/2021, an outbreak for Long-Term Care Facilities is defined as "one or more facility-acquired Covid-19 case in a resident".

Provider Information Notice (PIN) 20-04 issued 3/5/2020 states that facilities are to contact local public health immediately if there is a confirmed case and/or suspected outbreak of Covid-19 in the facility.

Multiple clients (4) were potentially exposed and placed at risk, on (3) separate occasions, when individual positive staff cases of Covid-19 were not reported within 24 hours to the Department.

Based on information obtained, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Facility is not performing daily screening of staff or clients. LPA reviewed staff temperature logs that were completed showing recorded temperatures and any screening symptoms for Covid-19 for the period 2/25/2021 -12/2/2021. LPA reviewed resident temperature logs and observed them to be complete for months January - March 2021, partially complete for months October- November 2020, and there was no documentation available prior to October 2020. Administrator stated that resident/client temperatures were stopped in March 2021 and not taken again until October 2021. During this same time period, the facility had (2) staff test positive for Covid-19- in May and in September, 2021. PIN 20-38 issued 10/6/2020 provides updated guidance that if testing cannot be done per PIN 20-23, issued 6/26/2020, r esidents who are asymptomatic and who have not been exposed to a person with COVID-19 should be screened, at least on a daily basis, for fever, respiratory symptoms, or common symptoms of possible COVID-19 infection.

Based on information obtained, the Department finds the portion of the allegation pertaining to clients to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.