{"ref":"GA-HH-IC-01","title":"Infection Prevention and Control Program","category":"Infection control","own":false,"summary":"Sets up the Agency’s infection prevention and control program for every patient: standard precautions and bag technique on every visit, transmission-based precautions, surveillance of infections with a log reviewed monthly and fed into quality improvement, reporting of notifiable diseases to public health, staff health, and education for staff, patients, and caregivers.","inShort":["Clean your hands when you arrive, before and after care, after removing gloves, and before you leave.","Wear gloves for contact with blood or body fluids, and more protection if splashing is likely.","Clean your equipment with the approved disinfectant after every patient. Keep your bag off the floor and the bed.","Report signs of infection in a patient to the case manager the same day.","Do not make visits if you have a fever, vomiting, diarrhea, or a respiratory illness with fever."],"primaryCitation":"42 CFR §484.70","citations":["O.C.G.A. §31-12-2","Ga. Comp. R. & Regs. 111-8-31-.07(6)","Ga. Comp. R. & Regs. 111-8-31-.08(a)","Ga. Comp. R. & Regs. 111-8-31-.08(d)"],"federalCitations":["42 CFR §484.70","42 CFR §484.80(h)(4)(iv)","29 CFR §1910.1030","42 CFR §484.65"],"surveyorAsks":["Who leads your infection control program, and what does it cover?","Show me your infection log and what you did about the last trend you found.","How do your staff clean their equipment between patients?","How do you report a notifiable disease, and to whom?","How do you teach patients and caregivers about preventing infection?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"GA-HH-IC-01-A","title":"Infection Surveillance Log"}],"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"}]],[["Authority"],["Georgia’s home health agency rules have no separate infection control rule; they require LPNs to observe aseptic technique (Ga. Comp. R. & Regs. 111-8-31-.08(a)2), aides to be trained in maintaining a clean, healthful environment (.08(d)1), and health examinations in personnel records (.07(6)). This policy is adopted under those rules, O.C.G.A. §31-12-2 (notifiable diseases), and 29 CFR §1910.1030, and, if the Agency is Medicare-certified, under 42 CFR §484.70. The federal program is applied to all patients as the Agency’s own standard."]],[["Applies to"],["Every employee, contractor, and volunteer who visits patients or handles patient equipment or specimens, and the supervising nurse who leads the program."]],[["Status"],["Mandatory. Adherence is a condition of employment and of any contract for services. No provision may be waived, shortened, or varied by any employee."]],[["Not covered here"],["Bloodborne pathogens exposure control (Policy GA-HH-IC-02). Sharps and medical waste (Policy GA-HH-IC-03). Employee health examinations (Policy GA-HH-HR-02). Outbreaks that disrupt operations (Policy GA-HH-EP-01)."]],[["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 rule cited at Section 16. Policies on scope of services, admission and discharge, medical supervision and plans of treatment, emergency care, clinical records, personnel qualifications, and program evaluation are also reviewed each year by the group of professional personnel (Ga. Comp. R. & Regs. 111-8-31-.07(3)(a)). Each review is recorded at Section 19 whether or not the text changes."]],[["Amendment"],["Any change requires the approval of the governing body and the issue of a new version number. Superseded versions are retained for six years."]],[["Distribution"],["Master copy held in the policy manual at the parent office and each branch office. Staff named in the Applies to row receive it at orientation and when it changes."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(404) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy sets out the infection prevention and control program of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"},", whose goal is to prevent and control infections and communicable diseases among patients, caregivers, and staff."],"edited":false},{"heading":"2. Scope","body":["This policy covers program leadership, standard precautions, bag technique and equipment, transmission-based precautions, surveillance, public health reporting, staff health, and education, on every visit and at every Agency office."],"edited":false},{"heading":"3. Definitions","body":["For the purposes of this policy, the following terms have the meanings below. Ga. Comp. R. & Regs. 111-8-31 and 42 CFR Part 484 both say \"patient\", and this policy uses the same word for the person receiving home health services."],"table":{"caption":null,"headers":[["Term"],["Meaning"]],"rows":[[["Standard precautions"],["The basic infection prevention practices used with every patient on every visit: hand hygiene, protective equipment based on expected exposure, respiratory hygiene, safe injection practices, safe handling of sharps, and cleaning and disinfection of equipment."]],[["Transmission-based precautions"],["Added precautions (contact, droplet, or airborne) used for a patient known or suspected to have an infection spread by that route."]],[["Surveillance"],["The ongoing collection and review of information on infections among patients, to find problems and act on them."]],[["Agency-acquired infection"],["An infection that appears to have started while the patient was receiving Agency services, such as a urinary tract infection in a patient with an Agency-managed catheter or a wound infection."]],[["Notifiable disease"],["A disease, injury, or condition that the Georgia Department of Public Health has declared requires notice and reporting (O.C.G.A. §31-12-2(a))."]],[["Supervising nurse"],["The physician or registered nurse under whose supervision and direction skilled nursing and other therapeutic services are provided, who (or a similarly qualified alternate) is available at all times during operating hours (Ga. Comp. R. & Regs. 111-8-31-.07(5)). The Agency calls this person the supervising nurse: currently ",{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"},", with ",{"k":"field","name":"people.alternateSupervisingNurse.name","text":"Casey Sample, RN"},", ",{"k":"field","name":"people.alternateSupervisingNurse.title","text":"Alternate Supervising Nurse"}," as the alternate. If the Agency is Medicare-certified, the same person is normally also the clinical manager who oversees all patient care services and personnel (42 CFR §484.105(c))."]]]},"edited":false},{"heading":"4. Policy Statement (42 CFR §484.70)","body":["The Agency maintains and documents an infection control program whose goal is the prevention and control of infections and communicable diseases. If the Agency is Medicare-certified, this is a condition of participation: \"The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.\" (42 CFR §484.70). The Agency follows accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases (42 CFR §484.70(a)). It maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of its quality assessment and performance improvement (QAPI) program, with a method for identifying infectious and communicable disease problems and a plan for the appropriate actions expected to result in improvement and disease prevention (42 CFR §484.70(b)). It provides infection control education to staff, patients, and caregivers (42 CFR §484.70(c)). The Agency applies these requirements to all patients as the Agency’s own standard.\n\nDiseases the Georgia Department of Public Health declares to require notice are reported to the county board of health and the Department \"in a manner and at such times as may be prescribed\" (O.C.G.A. §31-12-2(a))."],"edited":false},{"heading":"5. Program Leadership","body":[],"list":[["The supervising nurse, ",{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", leads the program, with the alternate supervising nurse acting in the supervising nurse’s absence. The supervising nurse completes infection prevention training each year, as the Agency’s own standard."],["The supervising nurse reviews surveillance data each month, reports infection data and actions to each QAPI meeting (Policy GA-HH-QA-02), and reviews this program each year with the Administrator."],["The program follows current guidance from the Centers for Disease Control and Prevention (CDC) and the Georgia Department of Public Health. The supervising nurse checks for new guidance at least quarterly and whenever there is a public health alert."]],"ordered":false,"edited":false},{"heading":"6. Standard Precautions on Every Visit","body":[],"list":[["Hand hygiene. Clean hands with alcohol-based hand rub, or with soap and water when hands are visibly soiled or the patient may have an infectious diarrhea: on entering the home, before and after patient contact, before a clean or aseptic procedure, after removing gloves, after contact with the patient’s surroundings, and before leaving."],["Protective equipment. Wear gloves for contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items. Add a gown, mask, or eye protection where splashing or spraying is likely. Remove and discard protective equipment before leaving the patient’s area, then clean hands (Policy GA-HH-IC-02)."],["Respiratory hygiene. Staff with respiratory symptoms do not make visits (Section 11). Offer a mask to a coughing patient where tolerated."],["Safe injection practices. Use a new sterile needle and syringe for every injection, never reuse single-dose vials, and use a multi-dose vial for one patient only."],["Sharps. Use safety-engineered devices where available, never recap by hand, and discard sharps at once into a puncture-resistant container (Policy GA-HH-IC-03)."],["Aseptic technique. Use sterile technique for sterile procedures, as the nursing procedure manual sets out. LPNs observe aseptic technique when preparing equipment and materials for treatments (Ga. Comp. R. & Regs. 111-8-31-.08(a)2)."]],"ordered":false,"edited":false},{"heading":"7. Bag Technique, Equipment, and Supplies","body":[],"list":[["The supply bag is placed on a clean, dry, hard surface or a barrier, never on the floor or the bed, and is opened only after hand hygiene."],["Only the supplies needed for the visit are taken out. Unused supplies that went into the work area are left with the patient or discarded, never returned to the bag."],["Reusable equipment, such as a stethoscope, blood pressure cuff, thermometer, pulse oximeter, or scale, is cleaned and disinfected after each patient with an EPA-registered disinfectant, following the product’s contact time. Where possible, equipment is left in the home for a patient on transmission-based precautions."],["Patient-specific supplies stay in the patient’s home. Clean and dirty items are kept apart in the vehicle, and soiled items are bagged."],["Glucose meters and other point-of-care devices follow Policy GA-HH-CS-04."]],"ordered":false,"edited":false},{"heading":"8. Transmission-Based Precautions","body":[],"list":[["When a patient is known or suspected to have an infection spread by contact (for example, MRSA in a draining wound, C. difficile, or scabies), droplet (for example, influenza), or airborne (for example, active tuberculosis) routes, the case manager records the precautions in the plan of treatment and the aide’s written instructions and tells every staff member before the next visit."],["Staff use the protective equipment the precautions require. For airborne precautions, staff wear a fit-tested N95 or higher respirator under the Agency’s respiratory protection procedure."],["Where possible, the patient on precautions is scheduled as the last visit of the day."],["The patient and caregivers are taught how to prevent spread in the home, including hand hygiene, laundry, cleaning, and waste disposal."]],"ordered":false,"edited":false},{"heading":"9. Surveillance and Documentation of Infections","body":[],"list":[["Any staff member who notices signs of a possible infection, such as fever, new or increased wound drainage or redness, painful or cloudy urine, new cough, or diarrhea, reports them to the case manager the same day."],["The case manager tells the physician, records any orders, and follows up the result."],["When an infection is confirmed or treated, the case manager records it on the infection surveillance log (Form GA-HH-IC-01-A) and in the clinical record with the date detected, the patient’s name, primary diagnosis, signs and symptoms, type of infection, pathogens identified, treatment, and any device or procedure involved, as the Agency’s own standard."],["The supervising nurse reviews the log each month, calculates infection rates by type (for example, per 1,000 patient days, or per 100 patients with a urinary catheter), and looks for clusters, trends, and links to a staff member, procedure, or device."],["Where a problem is found, the supervising nurse investigates, records the findings, and puts in place an action plan (42 CFR §484.70(b)(2)). Actions and their results are reported to the QAPI program, and infection data also feed the annual program evaluation (Ga. Comp. R. & Regs. 111-8-31-.07(8); Policy GA-HH-QA-01)."]],"ordered":false,"edited":false},{"heading":"10. Reporting Notifiable Diseases and Outbreaks","body":[],"list":[["Where a patient is diagnosed with a notifiable disease, the supervising nurse confirms whether the physician or laboratory has reported it. Where the Department of Public Health requires the Agency to report, the supervising nurse reports it to the county board of health or the Department in the manner and within the time the Department requires for that disease (O.C.G.A. §31-12-2(a)). The current Georgia notifiable disease list and reporting times are kept with this policy and checked at each review."],["Any illness or condition that may be caused by bioterrorism, epidemic or pandemic disease, or a novel and highly fatal infectious agent or toxin is reported to the supervising nurse at once, who makes sure it is reported to the Department of Public Health and the county board of health (O.C.G.A. §31-12-2(b))."],["Disease reports are confidential (O.C.G.A. §31-12-2(a)); they are shared only as public health officials direct."],["The supervising nurse cooperates with public health officials in any investigation and follows their instructions."],["A suspected outbreak, such as two or more patients or staff with the same infection linked in time and place, is reported to the Administrator at once, and the emergency preparedness plan is used if needed (Policy GA-HH-EP-01)."]],"ordered":false,"edited":false},{"heading":"11. Staff Health","body":[],"list":[["Staff who have fever, vomiting, diarrhea, a draining skin lesion, conjunctivitis, or a respiratory illness with fever do not make visits and tell their supervisor before the shift. They return when the supervising nurse, following CDC guidance, clears them."],["Each staff member with patient contact has the health examination and tuberculosis screening in Policy GA-HH-HR-02, recorded in the personnel record (111-8-31-.07(6))."],["The Agency offers hepatitis B vaccination under Policy GA-HH-IC-02 and encourages annual influenza vaccination and other vaccinations CDC recommends for health care personnel. Records are kept in the confidential employee medical file."],["Staff with a work-related exposure to blood or body fluids follow Policy GA-HH-IC-02."]],"ordered":false,"edited":false},{"heading":"12. Education of Staff, Patients, and Caregivers","body":[],"list":[["Staff receive infection control education at orientation, before the first visit, and each year, covering this policy, hand hygiene, protective equipment, bag technique, precautions, surveillance reporting, and the bloodborne pathogens plan (42 CFR §484.70(c); Policy GA-HH-HR-01)."],["Home health aides comply with infection prevention and control policies and procedures, and this is checked at every aide supervisory visit (42 CFR §484.80(h)(4)(iv); Policy GA-HH-AID-02)."],["Patients and caregivers are taught at the start of care, and as needed, about hand hygiene, care of wounds, catheters, and devices, signs of infection to report, safe disposal of sharps (Policy GA-HH-IC-03), and cleaning in the home. The teaching is recorded in the clinical record."]],"ordered":false,"edited":false},{"heading":"13. Responsibilities","body":["Accountability under this policy is allocated as follows."],"table":{"caption":["Who is accountable for what"],"headers":[["Role"],["Responsibility under this policy"]],"rows":[[[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}],["Owns and leads the program; reviews surveillance monthly; reports notifiable diseases where required; reports to QAPI."]],[[{"k":"field","name":"people.alternateSupervisingNurse.name","text":"Casey Sample, RN"},", ",{"k":"field","name":"people.alternateSupervisingNurse.title","text":"Alternate Supervising Nurse"}],["Acts for the supervising nurse whenever the supervising nurse is unavailable."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Provides protective equipment, supplies, and training time; reviews the program each year."]],[["Case managers"],["Record infections on the log; set transmission-based precautions; teach patients and caregivers."]],[["All visiting staff"],["Follow standard precautions and bag technique on every visit; report signs of infection; stay home when ill."]]]},"edited":false},{"heading":"14. Records and Compliance Monitoring","body":["The infection surveillance log, monthly reviews, investigations, notifiable disease reports, and the annual program review are kept by the supervising nurse for at least six years, as the Agency’s own standard. Infection details are also recorded in each patient’s clinical record. Hand hygiene and protective equipment use are observed at aide supervisory visits and staff competency checks, and results go to the QAPI program."],"edited":false},{"heading":"15. Staff Training","body":["Delivered as Section 12 describes. The supervising nurse and alternate are also trained on surveillance methods and Georgia notifiable disease reporting."],"edited":false},{"heading":"16. References","body":["This policy implements the following authorities."],"list":[["O.C.G.A. §31-12-2, Notifiable Diseases"],["Ga. Comp. R. & Regs. 111-8-31-.07(6), Personnel Policies (health examinations)"],["Ga. Comp. R. & Regs. 111-8-31-.08(a)2 and (d)1, LPN Duties (aseptic technique); Aide Training"],["42 CFR §484.70, Infection Prevention and Control"],["42 CFR §484.80(h)(4)(iv), Aide Supervision: Infection Control"],["29 CFR §1910.1030, Bloodborne Pathogens"]],"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":[[["Policy GA-HH-IC-02"],["Bloodborne Pathogens Exposure Control Plan"]],[["Policy GA-HH-IC-03"],["Sharps, Medical Waste, and Patient Instruction"]],[["Policy GA-HH-CS-04"],["Laboratory Services and Waived Testing"]],[["Policy GA-HH-HR-01"],["Personnel Policies, Qualifications, Orientation, In-Service Training, and Evaluation"]],[["Policy GA-HH-HR-02"],["Personnel Records and Employee Health Examinations"]],[["Policy GA-HH-AID-02"],["Home Health Aide Assignment, Written Instructions, and Supervisory Visits"]],[["Policy GA-HH-EP-01"],["Emergency Preparedness Program"]],[["Policy GA-HH-QA-01"],["Annual Program Evaluation and Quarterly Clinical Record Review"]],[["Policy GA-HH-QA-02"],["Quality Assessment and Performance Improvement (QAPI)"]],[["Form GA-HH-IC-01-A"],["Infection Surveillance Log"]]]},"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 rule cited in Section 16 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"ga-hha","state":"Georgia","service":"Home health","guides":[{"path":"/guides/infection-control-policy/","h1":"What should a home care infection control policy include?"},{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"sample":true,"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}