Effective November 28, at least one designated infection preventionist who meets specific education, training, and time requirements must be responsible for the infection prevention and control program in every Medicare- and/or Medicaid-certified skilled nursing facility/nursing facility (SNF/NF). One of those responsibilities is to be a member of the quality assessment and assurance (QAA) committee and to regularly report to the committee about the infection prevention and control program.
While the Centers for Medicare & Medicaid Services (CMS) proposed a change to the current hourly requirements for the infection preventionist position in the Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency, and Transparency Proposed Rule released on July 16, the agency does not want to change the implementation timeline for the infection preventionist requirements.
“We do not propose to delay those requirements related to the infection preventionist at §483.80(b)(1) through (4), (c) and §483.75(g)(1)(iv),” says CMS. “We do not propose to delay the implementation of the infection preventionist requirements because the reduction in burden is related to the time required onsite. The requirements related to the infection preventionist’s required training and role remain unchanged, and we therefore believe this requirement can be implemented as scheduled.”
“CMS’s expectations for the QAA committee have changed,” says Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and faculty member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA.
“The agency now takes a more professional, evidence-based stance as it does with long-term care overall, expecting the QAA committee to have a data-driven approach to quality and safety,” explains Burdsall. “Since the 2010 passage of the Affordable Care Act, CMS also has tasked the Quality Improvement Network-Quality Improvement Organizations (QIN-QIOs) with giving providers the education and tools necessary to understand the Quality Assurance and Performance Improvement (QAPI) process that underpins the QAA committee. Consequently, most providers should be prepared for all of the upcoming QAPI/QAA changes.”
Nevertheless, directors of nursing services (DNSs) can optimize the relationship between the infection preventionist and the QAA committee by considering the following steps:
Look at what data is being reported
Infection prevention and control, like epidemiology, is a mature discipline, says Burdsall. “However, these disciplines aren’t necessarily taught in nursing school. Consequently, when nurses first take on the job of infection preventionist, they sometimes think ‘If I just collect all of the antibiotics ordered, the culture results, and the diagnoses of who has an ‘infection,’ then my job will be done.’ The infection preventionist—like anyone reporting data into QAPI/QAA—needs to be more systematic than that.”
The first step is to have a strong facility assessment, advises Burdsall. “Many DNSs have missed the boat on the importance of the facility assessment. Basically, the entire QAPI/QAA process, including infection prevention and control, needs to tie into that facility assessment. So the DNS should sit down with an interdisciplinary team and make sure that the facility assessment reflects what is currently happening in the facility.”
The QIN-QIOs developed a free, optional tool that providers can use to develop a strong facility assessment, says Burdsall. Note: Find the tool here.
The second step is to create an infection prevention and control risk assessment that assesses risk using the facility assessment as a starting point, says Burdsall. “There are some excellent tools that are online and free, so providers don’t have to reinvent the wheel. For example, SPICE (Statewide Program for Infection Control and Epidemiology) at the University of North Carolina at Chapel Hill has the Template Risk Assessment for LTC, and the Centers for Disease Control and Prevention (CDC) offers the Infection Control Assessment Tool for Long-term Care Facilities.”
Providers can use these tools in combination with the facility assessment to collect baseline risk data, suggests Burdsall. “Doing this gives facilities the systematic way that they need under the revised requirements of Medicare/Medicaid participation to identify gaps in infection prevention and control that require targeted data collection.”
Note: CDC Infection Control and Response (ICAR) training slides offer a glimpse of common problem areas identified in the CDC’s Infection Control Assessment Tool for Long-term Care Facilities as of February 2018. For example, under the Personal Protective Equipment (PPE) section of the tool, only 30 percent of providers met the standard, “The facility audits (monitors and documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing),” and only 40 percent met the standard, “The facility provides feedback to personnel regarding their PPE use,” in a survey of more than 2,000 facilities. If CDC updates this data for 2019 within the next few months, it will be posted here.
Providers then can use the QAPI process that is underneath the QAA committee “to review that information they have gathered to determine where they need performance improvement projects (PIPs),” says Burdsall. “Most facilities will need to have interdisciplinary teams develop at least one PIP that addresses basic infection prevention issues (e.g., hand hygiene or environmental cleaning and disinfecting).”
Some providers make the mistake of setting arbitrarily standardized time limits on PIPs, she adds. “For example, I’ve heard DNSs say, ‘This is our PIP for this month, and then next month we will do this other PIP.’ That’s not how PIPs work. The timeline of a PIP, which should be included in the PIP’s charter that is set by the QAA committee, needs to be customized to fit the goals and scope of each PIP.” Note: For more information, see QAPI at a Glance: A Step-by-Step Guide to Implementing QAPI in Your Nursing Home.
Don’t shortchange infection preventionist’s time/resources
“The infection preventionist must have sufficient time and resources,” says Burdsall. “The number of hours that are required for the infection preventionist will be based off of two factors: the facility assessment and the infection prevention and control risk assessment.”
For example, two nursing homes might both have 106 beds. “However, if one facility has minimal short-stay Medicare Part A residents and the other has a heavy Part A caseload with residents who require ventilators, dialysis, and enteral feeding in multi-bed rooms, these two facilities will each have completely different infection control challenges,” points out Burdsall. “In order to be able to collect the data and actually do something about the gaps that are identified, providers have to make sure that the infection preventionist position is adequately staffed.”
In many facilities, the DNS or the assistant DNS has been charged with infection prevention and control, says Burdsall. “While this approach may work in some facilities, in others it may not. We’re reaching the point where, for example, having the DNS in a 200-bed facility serve as the sole infection preventionist would be very similar to having that DNS also be the one and only MDS coordinator. A facility that did that would end up closing down.”
Facilities may want to consider looking outside nursing for an infection preventionist, she adds. “For example, laboratorians and people with a master’s degree in public health are entering infection prevention and control, which brings fresh, interdisciplinary eyes to the field. And infection prevention and control programs can be staffed under human resources, staff development, and other departments.”
Plan for life-long learning
“Whoever is involved in infection prevention and control should start with the CDC’s free online Nursing Home Infection Preventionist Training Course,” says Burdsall. “However, that course just scratches the surface. It is the first step in the lifelong learning necessary to practice infection prevention and control.”
The CDC and organizations like APIC offer additional educational resources, says Burdsall. “For example, APIC has an online course, in-person training, and a national conference the same way that AADNS does. It’s important that the infection preventionist become involved in the larger world of infection prevention and control. Germs are always changing, so the infection preventionist will be left behind pretty quickly if education isn’t ongoing and they don’t get involved in the broader community.”
Report data into NHSN
The National Healthcare Safety Network (NHSN) is the mechanism that the CDC uses to “collect, analyze, summarize, and provide data on healthcare-associated infections (HAIs), other adverse health events, antimicrobial use and resistance, adherence to prevention practices, and use of antimicrobial stewardship programs,” according to the NHSN training slide set, Tracking Infections in Long-term Care Facilities (LTCFs) Using the National Healthcare Safety Network (NHSN) Overview.
“The NHSN is a required reporting system for acute care, dialysis centers, and certain other facilities,” says Burdsall. “Right now, it is voluntary for SNFs/NFs. However, I believe that it will no longer be voluntary within the next few years.”
DNSs will save themselves headaches down the road if they ensure that the infection preventionist gets the facility signed up for and reporting into NHSN before it becomes mandatory, suggests Burdsall. “Once enough long-term care providers sign up to report, the CDC will be able to provide facilities with comparison data on infection rates similar to quality measures, so eventually it will help with QAPI/QAA.”
Note: While comparative data currently may be lacking for long-term care, participating SNFs/NFs do have access to data sets and analysis reports generated from their own reporting to guide prevention efforts, according to the NHSN.
Once enrolled in the NHSN, providers have to complete an annual survey of facility characteristics and practices, as well as submit process and outcome data manually or electronically—using standardized surveillance methods and definitions—to the NHSN component(s) they have signed up for. Two NHSN components are available to SNFs/NFs:
- Long-term Care Facility Component:
- Tracks resident infections:
- Healthcare-Associated Infection Module for Urinary Tract Infections,
- Laboratory-Identified Event Module for Clostridioides difficile Infection and Multidrug-Resistant Organisms, and
- Tracks staff adherence with hand hygiene and gown/glove use;
- Tracks resident infections:
- Healthcare Personnel Safety Component:
- Healthcare Personnel Vaccination Module, which tracks staff influenza vaccinations.
Note: Learn how to enroll in either NHSN module here.
Avoid the numbers trap
Sometimes providers fall into the trap of thinking that data is always meaningful, says Burdsall. “However, a beautiful infection control notebook doesn’t mean anything if the infection preventionist isn’t doing appropriate systematic monitoring to correctly identify gaps and issues; correctly assessing problems; doing education, training, and competencies where they need to be done; and feeding information back to the frontline staff who are providing the care that will have a meaningful impact on infection prevention and control. In other words, the infection preventionist should be out of the office seeing what is happening on the floor in order to report not just infection rates to the QAA committee but also, for example, what trainings have occurred, where the training gaps are, and where the competency gaps are that could increase the risk of infection.”
Banish departmental siloes
Everyone in the facility, including the infection preventionist, has to understand that there are no departmental siloes in infection prevention and control, says Burdsall. “That can get a little tricky. For example, an infection preventionist who is the DNS or another member of the nursing department currently may not have authority over environmental services, but they still have responsibility for any issues in environmental services under the infection prevention and control program they are charged with managing.”
In acute care where infection prevention and control is a mature discipline, the infection preventionist has significant authority, she notes. “For example, the infection preventionist can stop a major construction project in acute care if they identify breaches in infection prevention and control. The infection preventionist in long-term care needs a similar level of authority. With the exception of the administrator or the CEO, it’s probably the most interdisciplinary position in long-term care.”
§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.
(a) Infection prevention and control program. The 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, 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;
- 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 disease or infections should be reported;
- Standard and transmission-based precautions to be followed to prevent spread of infections;
- When 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.
- 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; and
- 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.
(b) Infection preventionist. The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility’s IPCP. The IP must:
- Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;
- Be qualified by education, training, experience or certification;
- Work at least part-time at the facility;* and
- Have completed specialized training in infection prevention and control.
(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.**
(d) Influenza and pneumococcal immunizations—
- Influenza. The facility must develop policies and procedures to ensure that—
- Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization;
- Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;The resident or the resident’s representative has the opportunity to refuse immunization; and
- The resident’s medical record includes documentation that indicates, at a minimum, the following:
- That the resident or resident’s representative was provided education regarding the benefits and potential side effects of influenza immunization; and
- That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.
- Pneumococcal disease. The facility must develop policies and procedures to ensure that—
- Before offering the pneumococcal immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization;
- Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
- The resident or the resident’s representative has the opportunity to refuse immunization; and
- The resident’s medical record includes documentation that indicates, at a minimum, the following:
- That the resident or resident’s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
- That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.
* Editor’s note 1: In the Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency, and Transparency Proposed Rule released on July 16, CMS proposed to remove the requirement that the infection preventionist work at the facility “at least part-time” and insert that the IP must have sufficient time at the facility to meet the objective’s set forth in the facility’s infection prevention and control plan.
** Editor’s note 2: The requirement that an infection preventionist be a member of the facility’s QAA committee is also specified in §483.75(g)(1)(iv).
Source: Title 42, Part 483, Subpart B, Code of Federal Regulations.
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