Infection Prevention And Control Program Infection Prevention And Control

infection prevention and control program infection prevention and control program ======================================== mission of

Infection Prevention and Control Program
Infection Prevention and Control Program
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MISSION OF PROGRAM:
The primary mission is to establish and maintain an infection
prevention and control program designed to provide a safe, sanitary
and comfortable environment and to help prevent the development and
transmission of communicable diseases and infections
The facility establishes an Infection Prevention and Control Program
(IPCP) under which it:
*
A system for preventing, identifying, reporting, investigating,
and controlling infections and communicable diseases for all
residents, staff, volunteers, visitors, and other individuals
providing services under a contractual arrangement based upon the
facility assessment conducted according to §483.70(e) and
following accepted national standards;As linked to Facility
Assessment, §483.70(e),
*
Written standards, policies, and procedures for the program, which
must include, but are not limited to:
a.
A system of surveillance designed to identify possible
communicable diseases or infections before they can spread to
other persons in the facility;
b.
When and to whom possible incidents of communicable disease or
infections should be reported.
c.
Standard and transmission-based precautions to be followed to
prevent the spread of infections.
d.
When and how isolation should be used for a resident; including
but not limited to;
i.
The type and duration of the isolation, depending upon the
infectious agent or organism involved.
ii.
A requirement that the isolation should be the least restrictive
possible for the resident under the circumstances.
e.
The circumstances under which the facility must prohibit employees
with a communicable disease or infected skin lesions from direct
contact with residents or their food if direct contact transmits
the disease.
f.
The hand hygiene procedures to be followed by staff involved in
direct resident contact.
*
An antibiotic stewardship program that includes antibiotic use
protocols and a system to monitor antibiotic use.
*
A system for recording incidents identified under the facility’s
IPCP and the corrective actions taken by the facility.
The facility must designate one or more individual(s) as the infection
preventionist(s) (IP)(s) who is responsible for the facility’s IPCP.
*
Have primary professional training in nursing, medical technology,
microbiology, epidemiology, or another related field;
*
Is qualified by education, training, experience or certification.
*
Works at least part-time at the facility.
*
Has completed specialized training in infection prevention and
control.
§483.80 (c) IP participation on quality assessment and assurance
committee.
*
The individual designated as the IP, or at least one of the
individuals if there is more than one IP, must be a member of the
facility’s quality assessment and assurance committee and report
to the committee on the IPCP on a regular basis
*
The individual designated as the IP must be a member of the
facility’s quality assessment and assurance committee and report
to the committee on the IPCP on a regular basis.
*
The facility will conduct an annual review of its IPCP and update
their program, as necessary.
Intent of the Infection Prevention and Control Program
======================================================
The intent of this regulation is to assure that the facility develops,
implements, and maintains an Infection Prevention and Control Program
in order to prevent, recognize, and control, to the extent possible,
the onset and spread of infection within the facility.
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The Infection Preventionist
===========================
• Perform surveillance and investigation to prevent, to the extent
possible, the onset and the spread of infection.
==================================================================
• Prevent and control outbreaks and cross-contamination using
transmission-based precautions in addition to standard precautions.
===================================================================
• Use records of infection incidents to improve its infection control
processes and outcomes by taking corrective actions, as indicated.
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• Implement hand hygiene (hand washing) practices consistent with
accepted standards of practice, to reduce the spread of infections and
prevent cross-contamination; and
======================================================================
• Properly store, handle, process, and transport linens to minimize
contamination.
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Overview:
=========
Infections are a significant source of morbidity and mortality for
nursing home residents and account for up to half of all nursing home
resident transfers to hospitals. Infections result in an estimated
150,000 to 200,000 hospital admissions per year at an estimated cost
of $673 million to $2 billion annually. When a nursing home resident
is hospitalized with a primary diagnosis of infection, the death rate
can reach as high as 40 percent.
It is estimated that an average of 1.6 to 3.8 infections per resident
occurs annually in nursing homes. Urinary tract, respiratory (e.g.,
pneumonia and bronchitis), and skin and soft tissue infections (e.g.,
pressure ulcers) represent the most common endemic infections in
residents of nursing homes.9 Other common infections include
conjunctivitis, gastroenteritis, and influenza
Confirming and managing an infectious outbreak can be costly and
time-consuming. An effective facility-wide infection prevention and
control program can help to contain costs and reduce adverse
consequences. An effective program relies upon the involvement,
support, and knowledge of the facility’s administration, the entire
interdisciplinary team, residents, and visitors.
Critical aspects of the infection prevention and control program
include recognizing and managing infections at the time of a
resident’s admission to the facility and throughout their stay, as
well as following recognized infection control practices while
providing care (e.g., hand hygiene, handling and processing of linens,
use of standard precautions, and appropriate use of transmission-based
precautions and cohorting or separating residents). It is important
that residents’ conditions be reassessed because older adults may have
coexisting diseases that complicate the diagnosis of an infection
(e.g., joint degeneration vs. infectious arthritis, COPD versus
pneumonia), and they may also have atypical or non-specific signs and
symptoms related to infections, such as altered mental status,
function or behavior, and impaired fever response.
Because of the potential negative impact that a resident may
experience as a result of the implementation of special precautions,
the facility is challenged to promote the individual resident’s rights
and well-being while trying to prevent and control the spread of
infections.
Factors Associated with the Spread of Infection in Nursing Homes
Many factors contribute to a substantial severity and frequency of
infections and infectious diseases in nursing homes. These infections
can arise from individual or institutional factors or both. Modes of
transmission of infection include, but are not limited to:
*
Contact
*
Droplet
*
Airborne
Individual Factors
------------------
Examples of individual factors contributing to infections and the
severity of the infection outcomes in facility residents include, but
are not limited to the following:
---------------------------------------------------------------------
*
Medications affecting resistance to infection such as
corticosteroids and chemotherapy;
-----------------------------------------------------
*
Limited physiologic reserve (e.g., decreased the function of the
heart, lungs, and kidneys).
----------------------------------------------------------------
*
Compromised host defenses (e.g., decreased or absent cough reflex
predisposing to aspiration pneumonia, thinning skin associated
with pressure ulcers, decreased tear production predisposing to
conjunctivitis, vascular insufficiency, and impaired immune
function)
-----------------------------------------------------------------
*
Coexisting chronic diseases (e.g., diabetes, arthritis, cancer,
COPD, anemia).
---------------------------------------------------------------
*
Complications from invasive diagnostic procedures such as skin or
bloodstream infections.
-----------------------------------------------------------------
*
Impaired responses to infection (e.g., cell-mediated responses).
----------------------------------------------------------------
*
Increased frequency of therapeutic toxicity (e.g., declining
kidney and liver function).
------------------------------------------------------------
The elderly may also have atypical or non-specific signs and symptoms
related to infections including but not limited to:
*
Changes in cognition of the resident;
*
Altered mental status that prevents giving a full history; and
*
Coexisting diseases that complicate diagnosis (e.g., joint
degeneration vs. arthritis, COPD versus pneumonia).
Institutional factors
In addition to the individual factors, institutional factors also
support the transmission of infection among nursing home residents,
including but not limited to:
*
Pathogen exposure in shared communal living space (e.g., handrails
and equipment);
*
Common air circulation;
*
Direct/indirect contact with health care personnel/visitors/other
residents;
*
Direct/indirect contact with equipment used to provide care.
*
Transfer of residents to and from hospitals or other settings
Microorganisms may enter the resident through various points of entry
(direct or indirect) such as:
*
A handshake (body excretions and secretions on the hands can be
directly transmitted person to person);
*
A dressing change of an open wound without proper hand washing.
*
Incontinent care without proper hand washing.
*
Food handling with unclean hands.
*
Coughing or sneezing (viruses that produce colds and influenza are
found in saliva and sputum and can be transferred in droplets or
aerosol).
*
Resident-care devices (e.g., electronic thermometers or glucose
monitoring devices) may transmit pathogens if devices contaminated
with blood or body fluids are shared without cleaning and
disinfecting between uses for different residents.
*
Clothing, uniforms, laboratory coats, or isolation gowns used as
PPE may become contaminated with potential pathogens aftercare of
a resident colonized or infected with an infectious agent.
Residents can be exposed to potentially pathogenic organisms in
several ways, including but not limited to the following:
*
Improper hand hygiene;
*
Improper glove use (e.g., utilizing a single pair of gloves for
multiple tasks or multiple residents); and
*
Improper food handling
An effective infection prevention and control program is necessary to
control the spread of infections. Specific components of the infection
prevention and control program are critical to the operations of the
healthcare facility.
*
Identifying the staff’s roles and responsibilities for the routine
implementation of the program as well as in case of an outbreak of
a communicable disease, an episode of infection, or the threat of
a bio-hazard attack;
*
Developing and implementing policies and procedures to prevent the
spread of infections that include promoting consistent adherence
to evidence-based infection control practices;
*
Reviewing medical files upon admission and identify clients with
infectious diseases;
*
Developing plans of care for residents with infections that
include specific approaches to prevent the spread of infection to
others;
*
Monitoring and documenting infections, including tracking and
analyzing outbreaks of infection as well as implementing and
documenting actions to resolve related problems;
*
Defining and managing appropriate resident health initiatives
(i.e., immunization program, TB screening, and management);
*
Delegating a nursing home liaison to collaborate with local and
State health agencies;
*
Managing food safety, including employee health and hygiene, pest
control, investigating potential food-borne illnesses, and waste
disposal;
*
Training facility staff to identify the most common symptoms of
infections, i.e. a cough, fever, diarrhea, vomiting, and protocols
to prevent the spread of infections;
*
Launch an investigation to define the nature and magnitude of the
outbreak based on resident symptoms and facility trends.
*
Prepare lists of persons who are ill and try to identify recent
human and environmental contacts of each resident to facilitate an
infection management plans;
*
Communicate with the local Department of Public Health, State
Officials, and other key stakeholders for a more detailed
investigation by experts if the status of the outbreak warrants
such measures.
*
Designate rooms to isolate residents who have viral respiratory
infections, gastroenteritis, and other infectious diseases that
are transmitted by airborne droplets, contaminated food or water,
etc. so that new cases are prevented.
*
Ensure that rooms used for transmission based precautions for
residents with an infection contain hand hygiene equipment and
antibacterial hand cleansing dispenser;
*
Provide other resources needed to contain infections such as
disposable items, laundry facilities, and staff trained in
infection control;
*
Maintain training records that document training in
infection control in employee files;
*
Provide policies and procedures to protect staff from
infections;
*
Document previous illnesses and immunization status of
staff; and
*
Develop and implement written policies and procedures on how
to eliminate resident/resident and staff exposure to
infectious substances.
STRUCTURE OF THE INFECTION CONTROL PROGRAM:
The infection prevention and control program is under the direction of
a formal, designated committee or sub-committee such as an Infection
Prevention and Control Committee, Safety Committee or QAA Committee.
The members of this committee include persons who have day-to-day
responsibility for infection control practices as well as members of
the interdisciplinary team.
The Committee Functions:
1.
To recommend policy to the administration of the facility.
2.
To review infection control procedures by approved policy.
3.
To approve the goals and objectives of the infection control
program.
4.
To examine the findings of the approved surveillance programs.
5.
Review the antibiotic use and the antibiotic stewardship program.
6.
Review influenza and pneumococcal vaccine compliance.
7.
Review and discuss regulatory issues directly related to infection
prevention and control.
8.
Complete a yearly facility assessment.
The Infection Control and Prevention Committee oversight may be
composed of the following members:
*
Infection Preventionist
*
Medical Director
*
Representative from Nursing Department
*
Nursing Director
*
Representative from Administration
*
Occupational health – if separate from Infection Control
*
Others as appointed
a.
Members of the infection control and prevention oversight
committee support the infection preventionist to assure they
have adequate administrative support to direct the infection
control program.
b.
Written minutes and reports are maintained. The minutes reflect
problem identification and follow-up action.
c.
Statistical summaries of infections are compiled and analyzed by
the committee. Committee members disseminate these analysis
results to care unit staff as performance feedback. Records are
kept in a centralized location.
Elements of the Program Include:
*
Policies, procedures, and practices which promote consistent
adherence to evidence- based infection control practices;
*
Program oversight including planning, organizing, implementing,
operating, monitoring, and maintaining all of the elements of the
program and ensuring that the facility’s interdisciplinary team is
involved in infection prevention and control;
*
Infection preventionist is a person designated to serve as
coordinator of the infection prevention and control program.
*
Surveillance, including process and outcome surveillance,
monitoring, data analysis, documentation and communicable diseases
reporting (as required by State and Federal law and regulation)
*
Education, including training in infection prevention and control
practices, to ensure compliance with facility requirements as well
as State and Federal regulation.
*
Antibiotic review including reviewing data to monitor the
appropriate use of antibiotics in the resident population.
*
This Committee also communicates the findings from data collection
to the nursing home and directs changes in practice based on
identified trends, government infection control advisories, and
other factors.
*
Undertaking process and/or outcome surveillance activities to
identify infections that are causing, or have the potential to
cause an outbreak.
*
Conducting data analysis to help detect unusual or unexpected
outcomes and to determine the effectiveness of infection
prevention and control practices;
*
Documenting observations related to the causes of infection and/or
infection trends; and
*
Implementing measures to prevent the transmission of infectious
agents and to reduce risks for device and procedure-related
infections.
*
Defining and managing appropriate resident health initiatives,
such as:
*
The immunization program (influenza, pneumonia, etc.);
*
Tuberculosis screening on admission and following the discovery of
a new case, and managing active cases consistent with State
requirements;
*
Providing a nursing home liaison for working with local and State
health agencies.
*
Managing food safety, including employee health and hygiene, pest
control, investigating potential food-borne illnesses, and waste
disposal.
*
Identifying the staff’s roles and responsibilities for the routine
implementation of the program as well as in case of an outbreak of
a communicable disease, an episode of infection, or the threat of
a bio-hazard attack
*
Education, including training in infection prevention and control
practices, to ensure compliance with facility requirements as well
as State and Federal regulation
Policy and Procedure
*
Policies and procedures are the foundations of the facility’s
infection prevention and control program.
*
Policies and procedures are reviewed periodically and revised as
needed to conform to current standards of practice or to address
specific facility concerns.
*
Written policies establish the program’s expectations and
parameters. policies may specify the use of standard precautions
facility-wide and use of transmission-based precautions.
*
Define the frequency and nature of surveillance activities.
*
Ensure staff use accepted hand hygiene after each direct resident
contact for which hand hygiene is indicated. Prohibit and direct
resident contact by an employee who has an infected skin lesion or
communicable disease.
*
Procedures guide the implementation of the policies and
performance of specific tasks.
*
Procedures may include, for example, how to identify and
communicate information about residents with potentially
transmissible infectious agents.
*
Review the yearly facility assessment policy and procedure
STAFFING
The facility employs qualified and trained infection control staff to
direct and perform the infection control functions.
INFECTION PREVENTIONIST (IP)
----------------------------
The IP serves as the coordinator of an Infection Control and
Prevention program. The designated IP should have initial training in
either nursing, medical technology, microbiology, or epidemiology and
may possess additional training in infection control.
Responsibilities may include:
*
Collecting, analyzing, and providing infection data and trends to
nursing staff and healthcare practitioners;
*
Consulting on infection risk assessment, prevention, and control
strategies;
*
Providing education and training.
*
Implementing evidence-based infection control practices including
those mandated by regulatory and licensing agencies.
*
Participates and reports information on the facility Infection
Prevention and Control Program to the facility quality assessment
and assurance committee on a regular basis.
*
Completes yearly policy review
*
Participates in conducting the annual review of the Infection
Prevention and Control Program and updates the program as
necessary.
COMPLIANCE:
The infection control and prevention program is in compliance with
relevant federal, state, and local regulations.
DEFINITIONS (CMS Definitions):
“Airborne precautions” refers to actions taken to prevent or minimize
the transmission of infectious agents/organisms that remain infectious
over long distances when suspended in the air. These particles can
remain suspended in the air for prolonged periods of time and can be
carried on normal air currents in a room or beyond, to adjacent spaces
or areas receiving exhaust air.
“Alcohol-based hand rub” (ABHR) refers to a 60-95 percent ethanol or
isopropyl containing preparation base designed for application to the
hands to reduce the number of viable microorganisms
“Antifungal” refers to a medication used to treat a fungal infection
such as athlete’s foot, ringworm or candidiasis.
“Anti-infective” refers to a group of medications used to treat
infections.
“Antiseptic hand wash” is “washing hands with water and soap or other
detergents containing an antiseptic agent”.
“Cohorting” refers to the practice of grouping residents infected or
colonized with the same infectious agent together to confine their
care to one area and prevent contact with susceptible residents (cohort
residents). During outbreaks, healthcare personnel may be assigned to
a cohort of residents to limit opportunities for transmission (cohorts
staff).
“Colonization” refers to the presence of microorganisms on or within
body sites without detectable host immune response, cellular damage,
or clinical expression.
“Communicable disease” (also known as [a.k.a.] “Contagious disease”)
refers to an infection transmissible (as from person-to-person) by
direct contact with an affected individual or the individual's body
fluids or by indirect means (as by a vector).
“Community-associated infections” (formerly “Community Acquired
Infections”) refers to infections that are present or incubating at
the time of admission, or generally develop within 72 hours of
admission.
Contact precautions” are measures that are “intended to prevent
transmission of infectious agents, including epidemiologically
important microorganisms, which spreads by direct or indirect contact
with the resident or the resident’s environment.
“Droplet precautions” refers to actions designed to reduce/prevent the
transmission of pathogens spread through close respiratory or mucous
membrane contact with respiratory secretions.
“Hand hygiene” is a general term that applies to washing hands with
water and either plain soap or soap/detergent containing an antiseptic
agent, or thoroughly applying an alcohol-based hand rub (ABHR).
“Hand Washing” refers to washing hands with plain (i.e.
non-antimicrobial) soap and water.
“Health care-associated infection [HAI]” (a.k.a. “nosocomial” and
“facility-acquired” infection) refers to an infection that generally
occurs after 72 hours from the time of admission to a health care
facility
“Hygienically Clean” means being free of pathogens in sufficient
numbers to cause human illness.
“Infection” refers the establishment of an infective agent in or on a
suitable host, producing clinical signs and symptoms (e.g., fever,
redness, heat, purulent exudates, etc).
“Infection prevention and control program” refers to a program
(including surveillance, investigation, prevention, control, and
reporting) that provides a safe, sanitary and comfortable environment
to help prevent the development and transmission of infection.
“Infection preventionist (IP)” (a.k.a. infection control professional)
refers to a person whose primary training is in either nursing,
medical technology, microbiology, or epidemiology and who has acquired
additional training in infection control.
“Isolation” refers to the practices employed to reduce the spread of
an infectious agent and/or minimize the transmission of infection.
“Isolation precautions” see “Transmission-Based Precautions”
“Medical waste” refers to any solid waste that is generated in the
diagnosis, treatment, or immunization of human beings or animals, in
research pertaining to, or in the production or testing of biologicals
(e.g., blood-soaked bandages, sharps).
“Methicillin-resistant staphylococcus aureus (MRSA)" refers to
Staphylococcus aureus bacteria that are resistant to treatment with
semi-synthetic penicillin’s (e.g., Oxacillin/Nafcillin/Methicillin).
“Multi-Drug resistant organisms (MDROs)” refers to microorganisms,
predominantly bacteria, that are resistant to one or more classes of
antimicrobial agents. Although the names of certain MDROs describe
resistance to only one agent, these pathogens are frequently resistant
to most available antimicrobial agent.
“Outbreak” is the occurrence of more cases of a particular infection
than is normally expected, the occurrence of an unusual organism, or
the occurrence of unusual antibiotic resistance patterns.
“Personal protective equipment” (PPE) refers to protective items or
garments worn to protect the body or clothing from hazards that can
cause injury.
“Standard precautions” (formerly “Universal Precautions”) refers to
infection prevention practices that apply to all residents, regardless
of suspected or confirmed the diagnosis or presumed infection status.
Standard Precautions is a combination and expansion of Universal
Precautions and Body Substance Isolation (a practice of isolating all
body substances such as blood, urine, and feces)
“Surveillance” refers to the ongoing, systematic collection, analysis,
interpretation, and dissemination of data to identify infections and
infection risks, to try to reduce morbidity and mortality and to
improve resident health status.
“Transmission-based precautions” (a.k.a. “Isolation Precautions”)
refers to the actions (precautions) implemented, in addition to
standard precautions, that are based upon the means of transmission
(airborne, contact, and droplet) in order to prevent or control
infections.
“Vancomycin-resistant enterococcus (VRE)” refers to enterococcus that
has developed resistance to vancomycin
Centers for Medicare & Medicaid Manual System, Revision to State
Operations Manual (SOM) Appendix PP:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R167SOMA.pdf
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Infection Preventionist: Responsibility, Qualifications, and Functions
I.
RESPONSIBILITY:
The Infection Preventionist (IP), is responsible for directing the
infection prevention and control program.
II.
QUALIFICATIONS:
The IP must have primary professional training in nursing, medical
technology, microbiology, epidemiology, or another related field. The
IP is qualified by education, training, experience or certification.
Also, works at least part-time at the facility, and has completed
specialized training in infection prevention and control.
III.
CONTINUING EDUCATION:
The IP must maintain current knowledge in the field of infectious
disease and epidemiology.
Examples of ways to maintain current knowledge are to:
a.
Attend education programs provided by infection control
organizations.
b.
Collaborate with other infection control professionals.
a.
Well-informed on current practices regarding infection control and
epidemiology
a.
Actively seeks out learning opportunities to promote
professional growth.
b.
Access to best practice for infection prevention and control.
c.
Ongoing access to current federal, state and local regulations
on infection control requirements.
Administration provides adequate resources to assure that the IP
participates in continuing education.
IV.
AUTHORITY:
The Infection Preventionist has the authority to institute infection
control measures established through organizational policy and
procedures. The IP may establish isolation or other special
precautions, visitor restrictions, and outbreak control measures
V.
RESPONSIBILITIES: Policies and procedures are reviewed
periodically and revised as needed to conform to current standards
of practice or to address specific facility concerns.
*
Written policies establish the program’s expectations and
parameters
*
The policy may specify the use of standard precautions
facility-wide and use of transmission-based precautions when
indicated.
*
Define the frequency and nature of surveillance activities.
*
Require that staff use accepted hand hygiene after each direct
resident contact for which hand hygiene is indicated.
*
Prohibit direct resident contact by an employee who has an
infected skin lesion or communicable disease.
*
Identify and communicate information about residents with
potentially transmissible infectious agents
*
Instruct staff on caring for a resident on contact precautions.
*
Instruct on essential steps to cleaning equipment.
*
Identify the process for choosing agents for performing hand
hygiene.
*
Participates and reports on the Infection Prevention and Control
Program at the quarterly QAA committee as an active member.
*
Collaborates with the Medical Director on specific facility
concerns.
1.
Surveillance/Monitoring:
a.
Review microbiology culture and sensitivity report on a
regular basis to identify types of organisms causing
infections, antibiotic-resistant organisms, and transmission
of organisms between residents.
b.
Perform surveillance for infections, compile and analyze
data, prepare and bring reports to the Infection Prevention
and Control oversight committee.
c.
Plan and participate in process improvement activities as
needed and indicated by data analysis.
d.
Evaluate dietary, laundry, housekeeping, maintenance, and
nursing techniques to assure they are consistent with
recommended infection control practices.
e.
Monitor methods for waste disposal, pest control, and
traffic flow.
f.
Monitor antibiotic use to help determine if appropriate.
g.
Conduct environmental rounds within the facility to identify
potential breaches in infection control policies.
h.
Safeguard against exposure to a potential source of
infection.
i.
Uses appropriate hand hygiene prior to and after all
procedures.
j.
Ensures that appropriate sterile techniques are followed;
for example, that staff.
k.
Use sterile gloves, fluids, and materials, when indicated
depending on the site and the
l.
procedure
m.
Avoid contaminating sterile procedures by monitoring nursing
practice.
n.
Ensure that contaminated/non-sterile items are not placed in
a sterile field.
o.
Uses Personal Protective Equipment (PPE) when indicated.
p.
Ensures that reusable equipment is appropriately cleaned,
disinfected, or reprocessed; and
q.
Ensure single-use medication vials and other single use
items appropriately (proper disposal after every single
use).
2.
Practices:
a.
Recommend aseptic techniques and procedures to be used in
the facility.
b.
Assure that products and procedures for cleaning and
disinfection of surfaces and equipment are appropriate.
c.
Managing food safety, including employee’s health and
hygiene, pest control, investigating potential food-borne
illnesses, and waste disposal.
d.
Identifying the staff’s roles and responsibilities for the
routine implementation of the program as well as in the case
of an outbreak of a communicable disease, an episode of
infection, or the threat of a bio-hazard attack.
3.
Training:
a.
Confirms that initial and ongoing infection control education is
completed to help staff comply with infection control practices.
b.
Education and training are appropriate when there are policies and
procedures.
c.
Procedures that are revised when there is a special circumstance,
such as an outbreak are effectively communicated to staff.
d.
Task-specific infection prevention and control training is
discipline and tasks specific (e.g., insertion of urinary
catheters, suctioning, intravenous care or blood glucose
monitoring).
e.
Follow-up competency evaluations identify staff compliance.
f.
Essential topics of infection prevention and control training
include, but are not limited to routes of disease transmission,
hand hygiene, sanitation procedures, MDROs, transmission-based
precaution techniques, and the federally required OSHA education.
4.
Reporting:
a.
Report notifiable diseases to the public health department
as directed.
b.
Report findings of internal data analysis back to managers
and personnel as performance feedback.
c.
Establish and maintain a partnership with an infection
control professional at a local hospital and/or public
health agency to better understand infection control
concerns in the community.
d.
Communicate with other health care facilities regarding
residents who transfer into or out of the facility to
identify potential infectious diseases that may require
infection control precautions.
e.
It is important for each facility to have processes that
enable them to comply with State and local health department
requirements for reporting communicable diseases.
f.
The Infection Preventionist is a member and reports on the
facility Infection Prevention and Control Program to the QAA
committee at least quarterly.
g.
Review both the prevalence and incidence of infections at
the monthly infection prevention and control meeting.
5.
Policy Development and Review: Written standards, policies, and
procedures for the program, which must include, but are not
limited to:
:
a.
A system of surveillance designed to identify possible
communicable diseases or infections before they can spread to
other persons in the facility.
b.
When and to whom possible incidents of communicable disease or
infections should be reported;
c.
Standard and transmission-based precautions to be followed to
prevent spread of infections;
d.
When and how isolation should be used for a resident; including
but not limited to:
e.
The type and duration of the isolation, depending upon the
infectious agent or organism involved.
f.
A requirement that the isolation should be the least restrictive
possible for the resident under the circumstances.
g.
The circumstances under which the facility must prohibit employees
with a communicable disease or infected skin lesions from direct
contact with residents or their food if direct contact will
transmit the disease.
h.
The hand hygiene procedures to be followed by staff involved in
direct resident contact.
i.
An antibiotic stewardship program that includes antibiotic use
protocols and a system to monitor antibiotic use.
6.
Participates in conducting the annual review of the Infection
Prevention and Control Program and updates the program as
necessary.
VI.
ANTIBIOTIC REVIEW
a.
Review of the use of antibiotics (including comparing prescribed
antibiotics with available susceptibility reports) is a vital
aspect of the infection prevention and control program.
b.
Involve the consultant pharmacist with the oversight by
identifying antibiotics prescribed for resistant organisms.
c.
Track antibiotic use monthly and complete an antibiogram yearly.
d.
Review findings at the quarterly QAA meeting.
VII.
DELEGATION:
The Infection Preventionist may delegate certain monitoring
responsibilities to the nursing unit level.
The monitoring of infections and the infectious process is a
facility-wide responsibility. The Infection Preventionist will oversee
the Infection Prevention and Control Program.
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References
Centers for Medicare & Medicaid Services, October 4, 2016. Medicare
and Medicaid Programs; Reform of Requirements for Long-Term Care
Facilities.
https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
Centers for Medicare & Medicaid Manual System, Revision to State
Operations Manual (SOM) Appendix PP:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R167SOMA.pdf
Center for Disease Control and Prevention(CDC). Nursing homes and
Assisted Living(Long-term Care Facilities).
https://www.cdc.gov/longtermcare/staff.html

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