As is the case with many senior care providers during the pandemic, a prominent Midwest skilled nursing operator experienced an unfortunate infection control survey in late 2021. The survey resulted in the issuance of multiple citations, including an immediate jeopardy, which resulted in fines and the need for a third party to oversee the development of the plan of correction (Directed POC), as well as its implementation and ongoing monitoring for compliance validation over a 60-day period.

The Health Dimensions Group (HDG) project manager quickly mobilized and initiated communication with the state health department to coordinate the relay of HDG team credentials, which in this case, required a certified infection preventionist. The project commenced on September 13, 2021.


Assessment and Plan Development

HDG initiated the project with an initial on-site assessment, which included a tour of the physical plant and meetings with the community’s key leadership to establish and reinforce expectations of all parties involved in the scope of work. Through this collaborative approach, HDG and the client were able to quickly establish the positive working relationship needed for the heavy lift to come. The initial assessment informed the necessary approach given the nuances of the operation—especially the identification of other potential non-compliant practices the state surveyors may not have noticed during their infection control investigation. Once the assessment was complete, HDG successfully led the development of the plan of correction for approval by the state survey agency.

Root Cause / QAPI Analysis

Following the initial assessment, HDG consultants and the community’s team commenced a detailed Quality Assurance and Performance Improvement (QAPI) analysis to drill down to the root cause of non-compliance. The analysis focused on several key areas of the community’s infection control practices:

  • Infection control policies and procedures
  • Cohorting of residents under proper transmission-based precautions
  • Sanitation of equipment and environment in accordance with manufacture’s specifications
  • Hand hygiene
  • Use of personal protective equipment

Staff Training & Education

Once HDG established the educational curriculum, training commenced with all staff. Staff completed the curriculum through classroom learning and one-on-one sessions that facilitated live, real time interaction between consultants and staff. Staff education included the sharing of materials in verbal, visual, and written formats–all overseen by HDG consultants. Once training was complete, staff were required to return demonstrate their knowledge and skills resulting from the training. This approach was instrumental in identifying any patterns of failure where additional training and education could be applied immediately.

Compliance Monitoring

Once training and education concluded, the HDG team transitioned to ongoing auditing on all three shifts to gauge compliance with the corrective plan. Audits continued until 100 percent compliance was established.


Through the community team’s exceptional efforts to embrace the recovery roadmap created by HDG, the verification visit by state surveyors resulted in full compliance on October 19, 2021.

About Health Dimensions Group

Minneapolis-based Health Dimensions Group (HDG) is a leading management and consulting firm, providing services to post-acute, longterm care, and senior living providers, as well as hospitals and health systems across the nation. HDG has been serving health care organizations for more than 20 years with a firm commitment to its values of hospitality, stewardship, integrity, respect, and humor.


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