infection control program overview, responsibilities and qa … files/am 19... · experience,...

#28‐Infection Prevention Control Program Overview, Infection Preventionist

responsibilities and QA

Teresa Remy

Thursday 11/21/2019

2 PM ‐ 3 PM

KBN # 5‐0002‐12‐19‐586

1. | October 21, 2019

Infection Prevention Control Program Overview,Infection PreventionistResponsibilities and QATeresa RemyDirector of Consulting

2. | October 21, 2019

Teresa RemyDirector of Consulting, LeaderStat

Teresa has nearly 37 years of experience working in healthcare. As the Director of Consulting at LeaderStat, her areas of experience include the entire continuum of care from Acute Care to every aspect of Post-Acute Care such as Sub-acute, Skilled Nursing, Residential Care/ Assisted Living, Home Care, Hospice/ Palliative Care and Private Duty. Teresa has also been a Healthcare Facilities Surveyor, therefore, her focus on the importance of regulations and quality, combined with her years of experience, enable Teresa to use her expertise and talent to assist others in achieving excellence. Teresa has a proven record of achieving consecutive 5- Star Ratings, National Quality Awards, U.S News and World Report Best Nursing Home Awards, perfect surveys as well as working with multi-facility chains in achieving exceptional results.

[email protected]

3. | October 21, 2019

Learning Objectives Identify and understand:

1. The components of an infection prevention and control program (IPCP)

2. The role and responsibilities of the Infection Preventionist (IP)

3. How to integrate your IPCP into your QAPI and training programs to meet the revised Requirements of Participation

4. | October 21, 2019

• 1 to 3 million serious infections occur every year in these facilities

• Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others

• Infections are a major cause of hospitalization and death• As many as 380,000 people die of the infections in

LTCFs every year

5. | October 21, 2019

Deficiency Trends

• Glucometer cleaning• Respiratory equipment • Hand washing • Peri care• Medication

administration • Wound care • Transmission-based

precautions • TB testing of the residents

6. | October 21, 2019

Infection Prevention and Control Program

7. | October 21, 2019

F 880§483.80 Infection Control

The facility must 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.

8. | October 21, 2019

F 880The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

A system for:Preventing,Identifying,Reporting,Investigating, andControlling

…infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment.

9. | October 21, 2019

F 880The facility must establish an infection prevention and control program (IPCP) that must include written standards, policies, and procedures for the program, which must include, but are not limited to:

• A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

• When and to whom possible incidents of communicable diseases or infections should be reported;

• Standard and transmission-based precautions to be followed to prevent spread of infections

10. | October 21, 2019

F 880When and how isolation should be used for a resident, including but not limited to:

• The type and duration of the isolation, depending upon the infectious agent or organism involved, and

• A requirement that the isolation should be the least restrictive possible for the resident under the circumstances

11. | October 21, 2019

F 880When and how isolation should be used for a resident, including but not limited to (cont’d):

• 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

• The hand hygiene procedures to be followed by staff involved in direct resident contact

• A system for recording incidents identified under the facility’s IPCP and corrective action taken

12. | October 21, 2019

F 880Other updates to regulation – linens:

• Handling• Storage• Processing • Transporting

13. | October 21, 2019

F 880Other updates to regulation – annual review:

The facility will conduct an annual review of its IPCP and update the program as necessary

14. | October 21, 2019

F 882: Infection Preventionists

15. | October 21, 2019

F 882: (effective November 28, 2019)

The facility must designate one or more individual(s) as the Infection Previentionist (IP)(s) who are responsible for the facility’s IPCP

16. | October 21, 2019

IP Qualifications and Requirements

• §483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

• §483.80(b)(2) Be qualified by education, training, experience or certification;

17. | October 21, 2019

IP Qualifications and Requirements

• §483.80(b)(3) Work at least part-time at the facility (recently proposed “sufficient time”); and

• §483.80(b)(4) Have completed specialized training in infection prevention and control.

18. | October 21, 2019

IP Job Duties

• Partners with the Medical Director for epidemiology/infectious diseases to develop, implement and evaluate annual infection prevention goals and action plan

• Partners with facility leaders, physicians, local, state, and national agencies on activities related to infection prevention

• Oversees the operations of the infection prevention, epidemiology, industrial hygiene, and relevant safety programs

19. | October 21, 2019

IP Job Duties

• Accountable for surveillance of healthcare-acquired and community-acquired infections

• Manages goal setting process for system, unit and physician goals related to healthcare-acquired infections and conditions

• Lead industrial hygiene program to anticipate, recognize, evaluate, mitigate and control workplace conditions

20. | October 21, 2019

IP Job Duties

• Participates in the national collaborativesand external reporting to CDC NHSN system, and other post acute-care specific quality organizations

• Authority and responsible for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control/OSHA are identified

21. | October 21, 2019

IP Job Duties

• Ensures that education and counseling on infection prevention is available for staff, volunteers, medical staff, patients, and parents

• Support and participate in interdisciplinary performance and quality improvement process

• Maintains current knowledge of federal, state and local regulations and ensures that the facility leaders are informed of appropriate issues

• Understands and complies with infection control, safety and OSHA procedures and regulations

22. | October 21, 2019

IP Role in QAPI

23. | October 21, 2019

IP Role in QAPI§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.

24. | October 21, 2019

Meeting those Requirements• IC sub committee• QAPI committee• Safety committee• Skin or At Risk committee• Participation in departmental meetings• Daily stand up/stand down meetings• Medical Director meetings

25. | October 21, 2019

Consider Participation• Strategic planning• Completion and review of the facility assessment• Educational plan development• New employee orientation development-core

competency development• Auditing-process and outcome

26. | October 21, 2019

Barriers

• TIME• VACANT POSITIONS• CLINICAL COMPETENCY• LACK of ALLOCATED RESOURCES TO EDUCATION AND

TRAINING• DATA RELIABILITY• UNDEVELOPED QAPI PROGRAM• Others?

27. | October 21, 2019

Strategies to Make the Best Use of Time and Talent• Train the Trainer Approach

• Mentor program - peer to peer competency validation• Education and Coaching

• Change in condition identification• Antibiotic stewardship• Back up systems - after hours, weekend, and holiday

surveillance• Nursing Home Leadership Training

• Surveillance• Auditing

28. | October 21, 2019

Strategies to Make the Best Use of Time and Talent• EMR optimization

• Access and creation of reports• Evidence-based resources

• Leadership support of research time• Application and use

29. | October 21, 2019

Using Evidence- Based Resources

Using Evidence-

Based Resources

Using Evidence-

Based Resources

30. | October 21, 2019

Resources

https://www.cdc.gov/longtermcare/prevention/index.htmlhttps://www.cdc.gov/infectioncontrol/guidelines/index.htmlhttps://www.leadingagemi.org/http://community.apic.org/sierra/resources/overviewhttps://www.cdc.gov/nhsn/ltc/uti/index.html

https://www.cdc.gov/longtermcare/prevention/index.html

https://www.cdc.gov/infectioncontrol/guidelines/index.html

https://www.leadingagemi.org/

http://community.apic.org/sierra/resources/overview

https://www.cdc.gov/nhsn/ltc/uti/index.html

31. | October 21, 2019

32. | October 21, 2019

Components

• Infection Control Program and infrastructure• Healthcare personnel and resident safety • Surveillance and disease reporting• Hand hygiene• Personal Protective Equipment (PPE)• Respiratory/cough etiquette• Antibiotic stewardship • Injection safety and point of care testing • Environmental cleaning

33. | October 21, 2019

Infection Control Program and Infrastructure

Elements to be assessed Assessment Notes/Areas for Improvement

A. The facility has specified a person (e.g., staff, consultant) who is responsible for coordinating the IC program.

o YES o NO

B. The person responsible for coordinating the infection prevention program has received training in IC

o YESo NO

C. The facility has a process for reviewing infection surveillance data and infection prevention activities (e.g., presentation at QAPI committee)

o YESo NO

34. | October 21, 2019


D. Written infection control policies and procedures are available and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-880), or standards

o YES o NO

E. Written infection control policies and procedures are reviewed at least annually or according to state or federal requirements, and updated if appropriate

o YESo NO

F. The facility has a written plan for emergency preparedness (e.g., pandemic influenza or natural disaster)

o YESo NO

Infection Control Program and Infrastructure

35. | October 21, 2019

Healthcare Personnel and Resident Safety


A. The facility has work-exclusion policies concerning avoiding contact with residents when personnel have potentially transmissible conditions which do not penalize with loss of wages, benefits, or job status

o YES o NO

B. The facility educates personnel on prompt reporting of signs/symptoms of a potentially transmissible illness to a supervisor

o YESo NO

C. The facility conducts baseline Tuberculosis (TB) screening for all new personnel

o YESo NO

36. | October 21, 2019



D. The facility has a policy to assess healthcare personnel risk for TB (based on regional, community data) and requires periodic (at least annual) TB screening if indicated

o YES o NO

E. The facility offers Hepatitis B vaccination to all personnel who may be exposed to blood or body fluids as part of their job duties

o YESo NO

F. The facility offers all personnel influenza vaccination annually

o YESo NO

37. | October 21, 2019



G. The facility maintains written records of personnel influenza vaccination from the most recent influenza season

o YES o NO

H. The facility has an exposure control plan which addresses potential hazards posed by specific services provided by the facility (e.g., blood-borne pathogens)

o YESo NO

I. All personnel receive training and competency validation on managing a blood-borne pathogen exposure at the time of employment

o YESo NO

38. | October 21, 2019

Surveillance and Disease ReportingElements to be assessed Assessment Notes/Areas for

ImprovementA. The facility has written intake procedures to identify potentially infectious persons at the time of admission

o YES o NO

B. The facility has system for notification of infection prevention coordinator when antibiotic-resistant organisms or C. difficile are reported by clinical laboratory

o YESo NO

C. The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility

o YESo NO

D. The facility has system to follow-up on clinical information, (e.g., laboratory, procedure results and diagnoses), when residents are transferred to acute care hospitals for management of suspected infections, including sepsis

o YES o NO

39. | October 21, 2019

Surveillance and Disease ReportingElements to be assessed Assessment Notes/Areas for

ImprovementDisease Reporting:A. The facility has a written plan for outbreak response which includes a definition, procedures for surveillance and containment, and a list of syndromes or pathogens for which monitoring is performed

o YESo NO

B. The facility has a current list of diseases reportable to public health authorities

o YESo NO

C. The facility can provide point(s) of contact at the local or state health department for assistance with outbreak response

40. | October 21, 2019

Hand Hygiene


A. Hand hygiene policies promote preferential use of alcohol based hand rub (ABHR) over soap and water in most clinical situations

o YES o NO

All personnel receive training and competency validation on HH at the time of employment

o YESo NO

C. All personnel received training and competency validation on HH within the past 12 months

o YESo NO

D. The facility routinely audits (monitors and documents) adherence to HH Note: If yes, facility should describe auditing process and provide documentation of audits

o YESo NO

41. | October 21, 2019

Hand Hygiene


E. The facility provides feedback to personnel regarding their HH performance

o YES o NO

F. Supplies necessary for adherence to HH (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in resident care areas (i.e., nursing units, resident rooms, therapy rooms)

o YESo NO

42. | October 21, 2019

Personal Protective EquipmentElements to be assessed Assessment Notes/Areas for

ImprovementA. The facility has a policy on Standard Precautions which includes selection and use of PPE (e.g., indications, donning/doffing procedures)

o YES o NO

B. The facility has a policy on transmission-based precautions that includes the clinical conditions for which specific PPE should be used (e.g., C. difficile, influenza)

o YESo NO

C. Appropriate personnel receive job-specific training and competency validation on proper use of PPE at the time of employment

o YESo NO

D. Appropriate personnel received job-specific training and competency validation on proper use of PPE within the past 12 months

o YESo NO

43. | October 21, 2019

Personal Protective EquipmentElements to be assessed Assessment Notes/Areas for

ImprovementE. The facility routinely audits (monitors and documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing)

o YES o NO

F. The facility provides feedback to personnel regarding their PPE use

o YESo NO

G. Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (i.e., nursing units, therapy rooms)

o YESo NO

44. | October 21, 2019

Respiratory Hygiene/Cough EtiquetteElements to be assessed Assessment Notes/Areas for

ImprovementA. The facility has signs posted at entrances with instructions to individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?

o YES o NO

B. The facility provides resources for performing hand hygiene near the entrance and in common areas

o YESo NO

C. The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility

o YESo NO

45. | October 21, 2019

Respiratory Hygiene/Cough EtiquetteElements to be assessed Assessment Notes/Areas for

ImprovementD. The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?

o YES o NO

E. All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens

o YESo NO

46. | October 21, 2019

Antibiotic Stewardship


A. The facility can demonstrate leadership support for efforts to improve antibiotic use (antibiotic stewardship)

o YES o NO

B. The facility has identified individuals accountable for leading antibiotic stewardship activities

o YESo NO

C. The facility has access to individuals with antibiotic prescribing expertise (e.g. ID trained physician or pharmacist)

o YESo NO

47. | October 21, 2019



D. The facility has written policies on antibiotic prescribing

o YES o NO

E. The facility has implemented practices in place to improve antibiotic use

o YESo NO

F. The facility has a report summarizing antibiotic use from pharmacy data created within last 6 months

o YESo NO

48. | October 21, 2019



G. The facility has a report summarizing antibiotic resistance (i.e., antibiogram) from the laboratory created within the past 24 months

o YES o NO

H. The facility provides clinical prescribers with feedback about their antibiotic prescribing practices

o YESo NO

I. The facility has provided training on antibiotic use (stewardship) to all nursing staff within the last 12 months

o YESo NO

J. The facility has provided training on antibiotic use (stewardship) to all clinical providers with prescribing privileges within the last 12 months

o YESo NO

49. | October 21, 2019

Injection Safety and Point of Care Testing Elements to be assessed Assessment Notes/Areas for

ImprovementA. The facility has a policy on injection safety which includes protocols for performing finger sticks and point of care testing (e.g., assisted blood glucose monitoring, or AMBG)

o YES o NO

B. Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures at time of employment

o YESo NO

C. Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures within the past 12 months

o YESo NO

50. | October 21, 2019

Injection Safety and Point of Care TestingElements to be assessed Assessment Notes/Areas for

ImprovementD. The facility routinely audits (monitors and documents) adherence to injection safety procedures during point of care testing (e.g., AMBG)

o YES o NO

E. The facility provides feedback to personnel regarding their adherence to injection safety procedures during point of care testing (e.g., AMBG)

o YESo NO

F. Supplies necessary for adherence to safe injection practices (e.g., single-use, auto-disabling lancets, sharps containers) are readily accessible in resident care areas (i.e., nursing units)

o YESo NO

51. | October 21, 2019

Environmental Cleaning


A. The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms

o YES o NO

B. The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. difficile)

o YESo NO

C. The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas

o YESo NO

52. | October 21, 2019

Environmental Cleaning


D. The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.)

o YES o NO

E. Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, and dental equipment) are cleaned and reprocessed appropriately prior to use on another patient

o YESo NO

F. Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment

o YESo NO

53. | October 21, 2019

Environmental CleaningElements to be assessed Assessment Notes/Areas for

ImprovementG. Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months

o YES o NO

H. The facility routinely audits (monitors and documents) quality of cleaning and disinfection procedures

o YESo NO

I. The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures

o YESo NO

54. | October 21, 2019

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61. | October 21, 2019

References

•Centers for Disease Control, Nursing Homes and Assisted Living (LTC Facilities) electronically retrieved from: https://www.cdc.gov/longtermcare/, August 4, 2017•Michigan Department of Health and Human Services, Infection Control in Health Care Settings, electronically retrieved from: http://www.michigan.gov, August 4, 2017•Retrieved 8/4/2017: Lake Superior Quality Improvement Network-Healthcare Associated Infections, Antibiotic Stewardship electronically retrieved from: https://www.lsqin.org/, August 4, 2017•APIC: Association for Professional in Infection Control and Epidemiology electronically accessed : https://apic.org/, August 4, 2017•Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, Centers for Medicare and Medicaid Services, electronically retrieved from: https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities, August 4, 2017

https://www.cdc.gov/longtermcare/

http://www.michigan.gov/

https://www.lsqin.org/

https://apic.org/

62. | October 21, 2019

References

•Core Elements of Antibiotic Stewardship for Long Term Care, electronically accessed from: https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html, August 4, 2017.•Infection Prevention and Control Assessment Tool for Long-Term Care Facilities, Centers for Disease Control and Prevention, https://www.cdc.gov/infectioncontrol/pdf/icar/ltcf.pdf•Healthcare- associated infections, electronically accessed from: https://www.cdc.gov/hai/prevent/ppe_train.html

https://www.cdc.gov/infectioncontrol/pdf/icar/ltcf.pdf

https://www.cdc.gov/hai/prevent/ppe_train.html

63. | October 21, 2019

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