Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
F945 in Massachusetts. Pick another state for the same tag.
Against expectation — 2024
Massachusetts cites F945 more often than its own record predicts
Versus expected share3.91×
3.91 times the share F945 takes of citations nationally.
Share of Massachusetts citations0.18%
Of every deficiency written in Massachusetts in 2024, this is the portion that was F945.
Massachusetts0.18%
National0.05%
Share of all citations that were F945.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Massachusetts surveyors wrote
F945 findings written in Massachusetts, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
F · No harm, potential for more than minimal, widespreadDecember 16, 2024
Based on document review and interview, the facility failed to ensure all staff were trained on standards, policies, and procedures for the facility's infection prevention and control program.
Findings include:
During an interview on 11/21/24 at 10:44 A.M., the Administrator provided the survey team with printouts of all the staff training that had been completed on their electronic training system in the last 12 months. He said he did not believe it was possible to obtain the content of the classes to provide to the surveyor. In addition, a list of all staff was provided to the survey team that totaled 163 staff members. …
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