Term Care Infection Control Long Term Care Infection ...

Long Term Care Infection Control  2/26/2014
Regulations 
Long Term Care Infection Control 
Regulations 

Hellen Adrian, RN, FANIII

MO State Training Coordinator
Department of Health & Senior Services

Division of Regulation & Licensure
Section for Long Term Care Regulation – Training Unit

3418 Knipp Dr, Suite F, P. O. Box 570
Jefferson City, MO 65102

[email protected]
573/526‐7886

LTC Infection Control Regulations Long Term Care Infection Control 
Learning Objectives Regulations 

1. Discuss regulations and interpretive guidelines  • Which regulations 
that pertain to infection control in the State  apply to my 
Operations Manual (SOM). home?

2. Review the regulations in the Missouri Division  • Where do I look to  
of Regulation and Licensure, Section for Long‐ find the 
Term Care Regulation, Licensure Regulations  regulations? 
Manual.

3. Use the state and federal regulations to assist 
you with  better infection control practices  and 
to achieve better survey results. 

LTC Infection Control Regulations  Long Term Care Infection Control 
Regulations 
F441

• January 1, 2013 – March 31, 2013 
(3 mo.)

• Cited 72 times 
• Second only to F281 professional 

standards (cited 94 times) 

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Surveying Infection Control 2/26/2014

• Determine whether facility has an  Surveying Infection Control
effective program to:
• Apply current IC standards & 
– Identify practices to determine causes & 
– Investigate means of transmission for infections 
– Control & or potential infections.
– Prevent infection.

Surveying Infection Control Surveying Infection Control

• Hand washing • Proper use of  • How does facility control spread of 
• Respiratory  disinfectants,  infection by visitors?
antiseptics & 
protection germicides, in  • What are IC policies for those with 
• Linen handling accordance with  tuberculosis (TB), AIDS, hepatitis B or 
• Housekeeping manufacturer’s  hepatitis C?
• Needle & hazardous instructions
• Waste disposal
• Other IC strategies

Surveying Infection Control Surveying Infection Control

• Are Standard Precautions practiced? • Do staff conduct risk assessment for 
occurrence of communicable disease for 
• Are residents isolated only to degree  residents & staff
needed, in least restrictive way possible?
• What measures are in place to prevent 
• Do staff know & follow facility policy &  communicable disease outbreaks (TB, 
protocol on hand washing? scabies, flu, methycillin‐resistant 
Staphylococcusaureus, etc.)

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2/26/2014

Surveying Infection Control General Tour of Facility

• Procedures to inform & involve local  • Cleanliness & environment
or state epidemiologist as necessary • Use of personal protective equipment
• Hand washing
– scabies
– Stations include soap & towels
• Linen handling

– Clean: covered storage
– Soiled: closed containers, off floor

General Tour of Facility Errors in Infection Control Technique

• Appropriate storage of supplies: • During  the survey:
– Clean: utility room separate from soiled If failures to follow standard technique are 
utility room, with no direct connection noted:
– Clean: hand‐washing station & work  – Verify system in place to monitor infection 
counter control practices of staff
– Soiled: clinical sink, hand‐washing station, – Ask direct caregiver staff what they do & 
work counter, separate covered containers for  whom they notify when signs of infection 
soiled linen & waste are noted.

• Isolation technique, as necessary
• Correct handling of infectious waste

Long Term Care Challenges Current standards address measures for
prevention of infections associated with:
(Current standards for prevention available –
standards guide our practice • Other non‐treatment examples:

• Intravenous therapy • Pressure sores ‐ Nursing assistant observed walking 
• Indwelling catheters down the hall with soiled linen clutched 
• Tracheostomy care • Bladder and bowel  to his/her chest area and not in a bag.
• Stoma care incontinence ‐ Isolation linen not noted as such.
• Respiratory care
• Immunosuppression • Factors which 
compromise a 
resident’s resistance 
to infection

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2/26/2014

Flu & Pneumonia Immunizations Air Movement

• Have immunizations have been offered to all  • Air flow should be from “clean to 
residents? less clean”
Interview:
– Administrator • Air flow from rooms with 
– Director of nursing contamination or odor problems 
– Medical director exhausted to outside

• Review clinical record to determine  • Vents clean & free from dust & soil
compliance.

Pressure Ulcer Pressure Ulcer

• Was standard of practice technique  • Was treatment current?
used during dressing changes? – Did staff technique follow standard of 
practice?
– Hand washing/glove use? 
– Correct handling of scissors,  • Potential for cross‐contamination present?
– Was drainage present?
dressings, tape, etc.? ‐Color
– Correct disposal of soiled dressing? ‐Odor
‐Amount

Urinary Tract Infection Urinary Tract Infection

• Do staff provide: • Catheter care & handling
– Proper peri‐care?
– Linen changes to prevent residents  – Catheter necessary by medical 
sitting or lying in soiled linens? diagnosis?

– Standards of practice followed in 
transfer to prevent backflow of urine?

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2/26/2014

Surveying Infection Control Kitchen & Food Service

• Written procedures for hand washing  • Food handling:
& cleanliness of whirlpools, paraffin  – Safety precautions
baths, moist hot pack units
• Food preparation:
• Procedures for soiled linen removal  – Area cleanliness maintained?
& storage – Pest management systems in 
place?
• Pest control program

Kitchen & Food Service Infection through Linens

• Food storage: • Do staff know & follow facility policy 
– Correct holding temperatures? for handling linen?

• Hazard analysis & critical control point: • Linens processed, transported, 
‐‐ Observe for correct technique stored & handled properly?

• Dishwasher: • Contact between clean & soiled 
– Correct water temperature maintained? linen?

• Wash & rinse sinks:
– Correct wash & sanitizing agents?

Infection through Linens Linen Handling by Staff

• Soiled linen storage areas well  • Surveyor observations should include:
ventilated & maintained? – Hand washing when required?
– Linens held away from clothing?
• Staff understand isolation linen  – Linen bags closed?
handling precautions? – Linen hampers covered?
– Clean linens covered?

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Linen Handling by Laundry 2/26/2014

• Surveyor observations should include: LTC Infection Control Regulation 
– Is hazardous waste identified?
– Do staff wear protective clothing? • Federal Regulation – F441
– Is water temperature or bleach rinse  • §483.65 Infection Control
sufficient to provide disinfection? • Revised October 2010 
– Do staff understand standard         • The facility must establish and maintain an 
precautions?
Infection Control Program designed to provide 
a safe, sanitary and comfortable environment 
and to help prevent the development and 
transmission of disease and infection. 

LTC Infection Control Regulation  Long Term Care Infection Control 
Regulation 
• §483.65(a) Infection Control Program 
• §483.65(b) Preventing Spread of 
• The facility must establish an Infection Control Program  Infection 
under which it: (1) When the Infection Control Program   
(1) Investigates, controls, and prevents  infections 
in the facility;  determines that a resident needs isolation 
(2) Decides what procedures, such as  isolation,  to prevent the spread of infection, the 
should be applied to an individual resident;  and  facility must isolate the resident. 
(3) Maintains a record of incidents and  corrective 
actions related to infections. 

Long Term Care Infection Control  Long Term Care Infection Control 
Regulation  Regulation 

(2) The facility must prohibit employees  (3) The facility must require staff to 
with a communicable disease or infected  wash their hands after each direct 
skin lesions from direct contact with  resident contact for which hand 
residents or their food, if direct contact will  washing is indicated by accepted 
transmit the disease.  professional practice. 

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2/26/2014

Long Term Care Infection Control  F441
Regulation 
• Intent
• §483.65(c) Linens 
• Personnel must handle, store,  • Definitions

process and transport linens so as to  • Overview – Infections
prevent the spread of infection.  – Significant source of morbidity and mortality
– Accounts for up to half of NH to hospital 
transfers
– Estimated cost in $ 673 million to $2 billion
– Note:  It is important that all IC practices 
reflect current CDC guidelines. 

F441 Long Term Care Infection Control 
Regulation F441
• Investigative protocol
‐ Compliance
‐ Additional tags to investigate
‐ Deficiency categorization

Long Term Care Infection Control Long Term Care Infection Control 
Regulation 

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CMS Scope and Severity 2/26/2014

CMS SCOPE AND SEVERITY Long Term Care Infection Control 
Regulation
IMMEDIATE JEOPARDY PoC PoC PoC
Standard Precautions
to resident health or safety Required: Cat. 3 Required: Cat. 3 Required: Cat. 3
Long Term Care Infection Control 
Optional: Cat. 1 Optional: Cat. 1 Optional: Cat. 2 Regulation 

Optional: Cat. 2 J Optional: Cat. 2 K Optional: Cat. 1 L In Missouri, all LTC Facilities must 
screen for TB all:
ACTUAL HARM PoC PoC PoC • Employees
• Volunteers
that is not immediate jeopardy Required: Cat. 2 Required: Cat. 2 Required: Cat. 2 • Residents for TB

Optional: Cat. 1 Optional: Cat. 1 Optional: Cat. 1

G H Optional: Temp. Mgmt. I

NO ACTUAL HARM with PoC PoC PoC

POTENTIAL FOR MORE Required: Cat. 1 Required: Cat. 1 Required: Cat. 2

THAN MINIMAL HARM that is Optional: Cat. 2 Optional: Cat. 2 Optional: Cat. 2

not immediate jeopardy D EF

NO ACTUAL HARM with No Plan of Correction PoC PoC

POTENTIAL FOR MINIMAL No Remedies

HARM Commitment to Correct

Not on HCFA-2567 A BC
WIDESPREAD
ISOLATED PATTERN

Substandard Care – if F221 – 225, F240 – 258, F309 – 334

Substantial Compliance Remedy Category 2 Remedy Category 3
Denial of Payment for New Admissions: Temporary Management;
Remedy Category 1 Denial of Payment for All Individuals; Termination
Directed Plan of Correction; Imposed by CMS;
State Monitor; and/or Optional:
and/or Civil Money Penalties Civil Money Penalties
Directed In-Service Training $50 - $3,000/day; $10,000/instance $3,050 - $10,000/day

Long Term Care Infection Control 
Regulation 

• F329 ‐‐ Unnecessary drugs – includes 
proper use of antibiotic therapy;

• F334 – Influenza and Pneumonia 
Immunizations;

• F371 – Sanitary conditions – food 
handling, storage, and delivery.

LTC Infection Control Regulation  LTC Infection Control Regulation 

• You may locate the State Operations Manual  • You may locate the state regulation 
(SOM) at the following web address: manual at the following web addresses:
– http://health.mo.gov/seniors/nursingh
• http://www.cms.gov/Regulations‐and‐ omes/pdf/LicensureRegulationsManua
Guidance/Guidance/Manuals/Downloads/som10 l.pdf or;
7_appendixtoc.pdf ‐ choose appendix P for the  – http://www.sos.mo.gov/.
Survey Protocol for Long Term Care Facilities

• Choose Appendix PP for the Regulations and 
Interpretive Guidelines for Long Term Care 
Facilities.  

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2/26/2014

LTC Infection Control Regulation  Additional Resources

• Missouri Sanitation Requirements for all long‐ • You may find other resources that 
term care facilities may be found at the following  include the Infection Control Guidelines 
website: for Long‐Term Care Facilities (2005) at 
the following website:
• http://www.sos.mo.gov/adrules/csr/current/19cs – http://health.mo.gov/seniors/nursingh
r/19c30‐87.pdf omes/lawsregs.php#Mans

• The food and drug code referenced in these 
regulations may be found at the following 
website: 

– http://www.fda.gov/Food/GuidanceRegulation/Retail
FoodProtection/FoodCode/ucm2016793.htm

Hand Washing Guidance

• You will find guidance from the CDC for hand 
washing at the following website:  
http://www.cdc.gov/handhygiene/.

• And in the Morbidity and Mortality Weekly 
Report
Recommendations and Reports October 25, 
2002 / Vol. 51 / No. RR‐16 

• http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

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