{"ref":"FL-HSP-IC-01","title":"Infection Control Program, Universal Precautions and Facial Coverings","category":"Infection control","own":false,"summary":"Sets the Agency’s infection control program for home, residential and inpatient care: leadership and approval by the medical director and governing body, CDC standard (universal) precautions, hand hygiene, PPE and transmission-based precautions, bag technique, cleaning equipment, biomedical waste under Chapter 64E-16, F.A.C., surveillance and outbreak response, reporting notifiable diseases to the county health department, staff health as an Agency standard, education of staff, patients and families, and the Agency’s facial covering policy under s. 408.824, F.S. and Rule 59A-35.125, F.A.C.","inShort":["Clean your hands before and after every patient contact.","Use gloves and other protective gear when you may touch blood or body fluids.","Clean shared equipment after each patient, and keep your bag off the floor.","Bag waste from your visit and take it away. Teach families how to handle waste at home.","Report infections to the infection control lead within one business day, and stay home when you are contagious."],"primaryCitation":"Rule 59A-38.004(3)(c), F.A.C.","citations":["Rule 59A-38.004(3)(a)16., (3)(c), F.A.C.","Rule 59A-38.006(5)(f), F.A.C.","Rule 59A-38.016(2), F.A.C.","s. 408.824, F.S.","Rule 59A-35.125, F.A.C.","s. 381.026, F.S.","Rule 64E-16.001(4), F.A.C.","Rule 64E-16.003(2), F.A.C.","Rule 64E-16.011(1)(a), F.A.C.","Rule 64D-3.029, F.A.C.","Rule 64D-3.030, F.A.C."],"federalCitations":["42 CFR §418.60","29 CFR §1910.1030"],"surveyorAsks":["Show me your infection control program and the medical director’s and governing body’s approval of its procedures.","How do your nurses carry and clean equipment between homes?","Show me your infection surveillance for the last quarter and what you did about any trend.","How do you handle biomedical waste generated during visits, and what do you tell families about waste at home?","Do you require anyone to wear a facial covering? Where is your facial covering policy posted?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"FL-HSP-IC-01-A","title":"Infection Surveillance Log"},{"ref":"FL-HSP-IC-01-B","title":"Facial Covering Policy and Opt-Out Notice"}],"sections":[{"heading":"Terms of Reference","body":["This section sets out the standing under which this policy is issued, who owns it, who is bound by it, and how it is kept current. It is not itself a procedure. The obligations begin at Section 1."],"table":{"caption":null,"headers":[["Item"],["Detail"]],"rows":[[["Issued by"],["The governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}]],[["Document owner"],[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}," (infection control lead), with ",{"k":"field","name":"people.medicalDirector.name","text":"Dr. Morgan Sample"},", ",{"k":"field","name":"people.medicalDirector.title","text":"Medical Director"}]],[["Authority"],["Adopted under Rule 59A-38.004(3)(a)16. and (3)(c), F.A.C.; procedures approved by the medical director and the governing body. Also s. 408.824, F.S., Rule 59A-35.125, F.A.C., Chapters 64E-16 and 64D-3, F.A.C. If the Agency is Medicare-certified, also 42 CFR §418.60."]],[["Applies to"],["All employees, contracted staff, students and volunteers in every setting, and patients, families and visitors as the program describes."]],[["Status"],["Mandatory."]],[["Not covered here"],["Occupational exposure to blood and other potentially infectious materials (Policy FL-HSP-IC-02). Emergency plans for epidemics (Policy FL-HSP-EP-01). Physical plant of residential and inpatient units (Policy FL-HSP-FAC-03)."]],[["Review"],["Reviewed by the document owner at least every ",{"k":"field","name":"settings.reviewFrequencyMonths","text":"12"}," months, and within 30 days of any amendment to a statute or rule cited in the References section. Each review is recorded in the Revision History."]],[["Amendment"],["Any change requires the approval of the governing body and the issue of a new version number. Superseded versions are retained for at least six years."]],[["Distribution"],["Master copy in the policy manual. Form FL-HSP-IC-01-B is posted as Section 11 requires."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(813) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy protects patients, families, visitors and staff by preventing and controlling infections and communicable diseases in every setting where the Agency gives care."],"edited":false},{"heading":"2. Scope","body":["This policy covers the infection control program for the Agency’s home-care, residential care and inpatient programs (Rule 59A-38.004(3)(c), F.A.C.), its offices, and care given in facilities where patients live."],"edited":false},{"heading":"3. Definitions","body":["The following terms have the meanings given below when used in this policy."],"table":{"caption":null,"headers":[["Term"],["Meaning"]],"rows":[[["Standard precautions"],["The CDC’s infection prevention practices used for every patient, whatever the diagnosis: hand hygiene, use of personal protective equipment based on expected exposure, respiratory hygiene, safe injection practices, safe handling of equipment and surfaces, and safe handling of waste and linen. They include the CDC’s earlier \"universal precautions\", which Rule 59A-38.004(3)(a)16., F.A.C. names."]],[["Transmission-based precautions"],["Contact, droplet and airborne precautions added to standard precautions for patients known or suspected to have infections spread in those ways."]],[["Biomedical waste"],["As defined in Rule 64E-16.002, F.A.C., including discarded sharps, and absorbent materials saturated with blood or body fluids contaminated with visible blood."]],[["Infection control lead"],["The supervising registered nurse, or another registered nurse the Administrator designates in writing, who manages the program day to day (Agency standard)."]],[["Facial covering"],["\"a cloth or surgical face mask, a face shield, or any other facial covering that covers the mouth and nose\" (s. 408.824(1)(b), F.S.)."]],[["Agency"],[{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},", a hospice licensed by the Florida Agency for Health Care Administration under Part IV of Chapter 400, Florida Statutes, and Chapter 59A-38, Florida Administrative Code, holding license number ",{"k":"field","name":"agency.licenseNumber","text":"000000"},". Florida law defines a hospice as \"a centrally administered corporation or a limited liability company that provides a continuum of palliative and supportive care for the terminally ill patient and his or her family\" (s. 400.601(3), F.S.)."]],[["Medicare-certified"],["The Agency participates in Medicare as a hospice under 42 CFR Part 418. Where this policy says \"If the Agency is Medicare-certified\", the duty comes from the Medicare Conditions of Participation and applies only when the Agency is certified; Florida licensure duties apply in every case."]]]},"edited":false},{"heading":"4. Policy Statement (Rule 59A-38.004(3)(c), F.A.C.; 42 CFR §418.60)","body":["\"Each hospice provider shall develop an infection control program which specifies procedures and responsibilities for inpatient, residential care and home-care programs. Procedures regulating the structure and function of this program shall be approved by the medical director and the governing body, and shall comply with federal and state laws regarding blood-borne pathogens, infection control and biohazardous waste\" (Rule 59A-38.004(3)(c), F.A.C.). The Agency keeps policies and procedures for implementing universal precautions as established by the Centers for Disease Control and Prevention (Rule 59A-38.004(3)(a)16., F.A.C.). If the Agency is Medicare-certified, it \"must maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases\" (42 CFR §418.60)."],"edited":false},{"heading":"5. Leadership and Approval","body":[],"list":[["The infection control lead manages the program, keeps the procedures current with CDC guidance, runs surveillance and training, and reports to the QAUR/QAPI committee at least quarterly (Agency standard)."],["The medical director and the governing body approve the procedures in this policy and each change, and the approval is recorded in the governing body minutes (Rule 59A-38.004(3)(c), F.A.C.)."],["The program is an integral part of the Agency’s quality program (42 CFR §418.60(b)(1)). The QAUR/QAPI committee reviews protocols for containment of communicable diseases as a high-risk activity and disposal of contaminated materials or other biomedical waste as a problem-prone activity (Rule 59A-38.006(5)(f), F.A.C.)."]],"ordered":false,"edited":false},{"heading":"6. Prevention Practices","body":["The Agency follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions (42 CFR §418.60(a)). Sections 6.1 to 6.5 are the minimum."],"edited":false},{"heading":"6.1 Hand hygiene","body":[],"list":[["Staff clean their hands with alcohol-based hand rub or soap and water before and after every patient contact, before clean or sterile tasks, after contact with body fluids or contaminated items, and after removing gloves."],["Soap and water are used when hands are visibly soiled and when caring for a patient with diarrhea that may be caused by Clostridioides difficile or norovirus."],["Fingernails are short; artificial nails are not worn by staff who give hands-on care (Agency standard)."]],"ordered":false,"edited":false},{"heading":"6.2 Standard and transmission-based precautions","body":[],"list":[["Gloves are worn for contact with blood, body fluids, mucous membranes, broken skin or contaminated items. Gowns, masks and eye protection are worn when splashes or sprays are likely."],["For patients with known or suspected infections spread by contact, droplets or the air, staff add the precautions the CDC recommends, and the nurse teaches the family how to protect themselves."],["Staff with respiratory symptoms practice respiratory hygiene and follow the work restrictions in Section 9."],["Facial coverings are worn only under Section 11."]],"ordered":false,"edited":false},{"heading":"6.3 Bag technique and equipment","body":[],"list":[["Nursing bags hold only clean supplies. The bag is placed on a clean, dry surface or barrier in the home, never on the floor, and is opened only after hand hygiene."],["Reusable equipment (stethoscopes, blood pressure cuffs, thermometers, pulse oximeters) is cleaned and disinfected with an EPA-registered disinfectant, following the product’s contact time, after each patient. Single-patient equipment stays in the home for patients on transmission-based precautions."],["Single-use items are never reused. Sterile supplies are checked for expiry and package integrity."]],"ordered":false,"edited":false},{"heading":"6.4 Clinical procedures","body":[],"list":[["Catheter care, wound care, injections, ostomy care, suctioning and similar procedures follow the Agency’s clinical procedures and aseptic technique where required."],["Safe injection practice: one needle and one syringe for one patient, one time; single-dose vials for one patient only; sharps placed at once in a puncture-resistant sharps container (Policy FL-HSP-IC-02)."],["In any residential unit, units are maintained in a manner which provides for managing personal hygiene needs of the patients and implementation of infection control procedures (Rule 59A-38.016(2), F.A.C.; Policy FL-HSP-FAC-03)."]],"ordered":false,"edited":false},{"heading":"6.5 Biomedical waste","body":[],"list":[["\"Health care providers shall inform their home user clients verbally and in writing of the recommended method for handling biomedical waste generated in the home setting. Health care providers who deliver in-home medical services shall remove or have removed by a registered biomedical waste transporter all biomedical waste generated during the performance of these services\" (Rule 64E-16.001(4), F.A.C.)."],["Staff bag biomedical waste they generate during a visit in red biomedical waste bags or sharps containers at the point of origin, and remove it or have it removed by a registered transporter. The nurse gives the family written instructions on handling waste they generate themselves (for example, a rigid, puncture-resistant container for sharps)."],["Where the Agency’s office, residential unit or inpatient facility stores biomedical waste, it keeps a written operating plan covering training, segregation, labeling, packaging, transport, storage and treatment, spill decontamination and a contingency plan; trains personnel who handle waste before they start and annually; and keeps biomedical waste records for 3 years (Rule 64E-16.003(2), F.A.C.). It obtains a Department of Health generator permit unless it produces less than 25 pounds of biomedical waste in each 30-day period (Rule 64E-16.011(1)(a), F.A.C.)."],["Linen soiled with blood or body fluids is handled with gloves, bagged where used and laundered under Policy FL-HSP-IC-02."]],"ordered":false,"edited":false},{"heading":"7. Evaluating the Patient and Home for Infection Risk","body":[],"list":[["At admission and at each visit, the nurse assesses the patient’s infection risks (devices, wounds, immune status, recent hospital stays, known infections) and the home environment (hand washing facilities, cleanliness, pests, food storage), and records them."],["The plan of care includes infection prevention measures and the teaching the patient and family need."],["For facility patients, the nurse follows the facility’s infection control procedures and shares information about infections with the facility (Policy FL-HSP-FAC-01)."]],"ordered":false,"edited":false},{"heading":"8. Surveillance, Outbreaks and Reporting","body":[],"list":[["The Agency maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases, with a method of identifying problems and a plan for actions expected to result in improvement and disease prevention (42 CFR §418.60(b))."],["Clinical staff report each new infection in a patient, and each infectious illness or exposure in staff, to the infection control lead within one business day (Agency standard). The lead records it on Form FL-HSP-IC-01-A and reviews the month for clusters and trends."],["When two or more linked cases or an unusual infection are found, the lead investigates with the medical director, puts control measures in place, informs affected patients, families and facilities, and contacts the county health department for advice."],["Each practitioner licensed under Chapter 464, F.S. (and the other chapters the rule names) who diagnoses, treats or suspects a notifiable disease or condition must report it or cause it to be reported (Rule 64D-3.030(1), F.A.C.). The Agency’s nurses meet this duty by reporting to the infection control lead, who makes the report to the county health department for the Agency, and the nurse confirms it was made."],["Reports are made in the time frame the Table of Reportable Diseases or Conditions in Rule 64D-3.029, F.A.C. gives for each disease (\"Suspect Immediately\", \"Immediately\", \"Next Business Day\" or \"Other\"), by telephone, fax, electronic transfer or another confidential means, with any subsequent written report the rule requires. Urgent reports outside county health department business hours go to the county after-hours duty official (Rule 64D-3.029(1)-(2), F.A.C.)."]],"ordered":true,"edited":false},{"heading":"9. Staff Health","body":["No Florida rule requires tuberculosis testing or a health statement for hospice staff. The measures below are the Agency’s own standards, based on CDC guidance for health care personnel."],"list":[["At hire, each person with patient contact completes a tuberculosis risk assessment and symptom screen and has a baseline tuberculosis test, unless documented results within the past 12 months are provided. Routine annual testing is not done unless an exposure or risk assessment calls for it."],["The Agency offers the influenza vaccine every year and other vaccines the CDC recommends for health care personnel, and offers the hepatitis B vaccine under Policy FL-HSP-IC-02. Vaccination records and declinations are kept in the confidential employee medical file (Policy FL-HSP-HR-05)."],["Staff with fever, vomiting, diarrhea, a draining wound, a rash that may be infectious, or another contagious illness tell their supervisor before visits and do not give patient care until the infection control lead or the staff member’s health care provider clears them."],["Staff exposed to a communicable disease are evaluated and followed up as CDC guidance recommends."]],"ordered":false,"edited":false},{"heading":"10. Education","body":[],"list":[["The Agency provides infection control education to employees, contracted providers, patients, family members and other caregivers (42 CFR §418.60(c))."],["Staff receive training at orientation and at least yearly on this policy, standard and transmission-based precautions, hand hygiene, bag technique, equipment cleaning, waste handling and reporting."],["The nurse teaches each patient and family hand hygiene, safe handling of waste and soiled linen, cleaning of equipment, and signs of infection to report, and records the teaching."]],"ordered":false,"edited":false},{"heading":"11. Facial Coverings","body":["A provider that requires any individual to wear a facial covering for any reason must have facial covering policies and procedures that comply with the state standards and that are \"accessible from the home page\" of its website or \"conspicuously displayed in the lobby\" (s. 408.824(3), F.S.). A provider \"may not require any person to wear a facial covering for any reason unless the requirement is in accordance with\" those standards and policies (s. 408.824(4)(a), F.S.)."],"list":[["The Administrator, with the infection control lead and the medical director, decides whether the Agency requires facial coverings in any setting. If it does, Form FL-HSP-IC-01-B is completed, linked from the home page of the Agency’s website, and displayed in the lobby of each office and any residential or inpatient unit."],["Patients may be required to wear a facial covering only when in a common area of the health care setting and showing signs or symptoms of, or diagnosed with, an infectious disease that can be spread through droplet or airborne transmission (Rule 59A-35.125(2), F.A.C.). The policy includes a provision for patients to opt out that is in accordance with the Florida Patient Bill of Rights and Responsibilities, s. 381.026, F.S. (Rule 59A-35.125(4)(a), F.A.C.)."],["Visitors may be required to wear a facial covering only in the four cases in Rule 59A-35.125(3)(a)-(d), F.A.C., and may opt out if an alternative method of infection control or infectious disease prevention is available (Rule 59A-35.125(4)(b), F.A.C.)."],["The Agency allows each employee (including contractors, students and volunteers) to opt out of facial covering requirements unless the employee is conducting sterile procedures; working in a sterile area; working with a patient whose treating practitioner has diagnosed or confirmed an immune condition that increases the risk of transmission and has determined facial coverings are necessary for the patient’s safety; with a patient on droplet or airborne isolation; or engaging in non-clinical potentially hazardous activities that require facial coverings to prevent physical injury or harm (Rule 59A-35.125(5), F.A.C.)."],["This section does not limit an employee’s use of respiratory protection that OSHA requires for a hazard (Policy FL-HSP-SAF-01)."]],"ordered":true,"edited":false},{"heading":"12. Annual Program Evaluation","body":["Each year the infection control lead evaluates the program: infection rates and trends, outbreak investigations, staff exposures, audits of hand hygiene and bag technique, waste handling, training completion and vaccination rates. The evaluation, with recommendations, goes to the QAUR/QAPI committee, the medical director and the governing body (Agency standard)."],"edited":false},{"heading":"13. Responsibilities","body":["Each role named below carries the duties shown."],"table":{"caption":null,"headers":[["Role"],["Responsibility"]],"rows":[[["Governing body and medical director"],["Approve the program procedures and each change."]],[["Infection control lead"],["Manages the program; keeps surveillance; investigates clusters; makes notifiable disease reports; trains staff; reports quarterly and yearly."]],[["Administrator"],["Provides supplies and PPE; decides on and posts any facial covering policy; arranges biomedical waste transport and any permit."]],[["Clinical staff"],["Follow precautions; teach patients and families; report infections and exposures within one business day; follow work restrictions."]],[["All staff and volunteers"],["Practice hand hygiene and respiratory hygiene; stay away from patients when contagious."]]]},"edited":false},{"heading":"14. Records and Compliance Monitoring","body":["Kept for the periods shown:"],"list":[["Form FL-HSP-IC-01-A, outbreak investigations, notifiable disease reports and the annual evaluation: five years (Agency standard)."],["Biomedical waste management records: 3 years (Rule 64E-16.003(2)(b), F.A.C.)."],["Infection control training records: three years (Agency standard; 29 CFR §1910.1030(h)(2)(ii) for bloodborne pathogens training)."],["Facial covering policy versions, with the dates each was posted: six years (Agency standard)."],["Approval of procedures by the medical director and governing body: governing body minutes."]],"ordered":false,"edited":false},{"heading":"15. Staff Training","body":["All staff and volunteers receive infection control training before their first patient contact and at least yearly, appropriate to their role. Nurses also receive training on surveillance, notifiable disease reporting and teaching families."],"edited":false},{"heading":"16. References","body":["This policy implements the following authorities."],"list":[["s. 381.026, F.S., Florida Patient’s Bill of Rights and Responsibilities"],["s. 408.824, F.S., Facial covering requirements"],["Rule 59A-35.125, F.A.C., Standards for the appropriate use of facial coverings"],["Rule 59A-38.004(3)(a)16., (3)(c), F.A.C., Universal precautions; infection control program"],["Rule 59A-38.006(5)(f), F.A.C., High-risk and problem-prone activities"],["Rule 59A-38.016(2), F.A.C., Residential units"],["Chapter 64D-3, F.A.C. (Rules 64D-3.029 and 64D-3.030), Reportable diseases and notification by practitioners"],["Chapter 64E-16, F.A.C. (Rules 64E-16.001, .002, .003, .011), Biomedical waste"],["29 CFR §1910.1030, Bloodborne pathogens"],["42 CFR §418.60, Infection control"]],"ordered":false,"edited":false},{"heading":"17. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Form FL-HSP-IC-01-A"],["Infection Surveillance Log"]],[["Form FL-HSP-IC-01-B"],["Facial Covering Policy and Opt-Out Notice"]],[["Policy FL-HSP-GOV-01"],["Governing Body, Bylaws and Annual Plans"]],[["Policy FL-HSP-MD-01"],["Medical Director and Physician Services"]],[["Policy FL-HSP-HR-01"],["Orientation, Hospice Training Program and Competency"]],[["Policy FL-HSP-HR-05"],["Personnel Files and Employment Records"]],[["Policy FL-HSP-NUR-01"],["Nursing Services, Supervising Registered Nurse and Coordinating Nurse"]],[["Policy FL-HSP-AIDE-01"],["Home Health Aides (Hospice Aides) and Homemakers"]],[["Policy FL-HSP-IC-02"],["Bloodborne Pathogens Exposure Control Plan"]],[["Policy FL-HSP-SAF-01"],["Staff Safety, Home Safety and Emergencies in the Home"]],[["Policy FL-HSP-DME-01"],["Medical Supplies and Durable Medical Equipment"]],[["Policy FL-HSP-EP-01"],["Comprehensive Emergency Management Plan and Emergency Preparedness Program"]],[["Policy FL-HSP-FAC-01"],["Hospice Care for Residents of Nursing Homes, Assisted Living Facilities and Adult Family-Care Homes"]],[["Policy FL-HSP-FAC-03"],["Hospice Residential Units and Freestanding Inpatient Facilities"]],[["Policy FL-HSP-QA-01"],["Quality Assurance and Utilization Review (QAUR) and QAPI Program"]]]},"edited":false},{"heading":"18. Approval","body":["This policy is adopted by the governing body of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},". The effective date, the person who approved it, and the date of approval are shown in the header block and recorded in the signature lines below."],"edited":false},{"heading":"19. Revision History","body":["Every version of this policy, the date it took effect, a summary of what changed, and who approved it is recorded below. Where a statute or rule cited in the References section is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"fl-hospice","state":"Florida","service":"Hospice","guides":[{"path":"/guides/infection-control-policy/","h1":"What should a home care infection control policy include?"},{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"sample":true,"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}