{"ref":"LA-HH-IC-01","title":"Infection Prevention and Control Program","category":"Infection control","own":false,"summary":"Sets out the Agency's infection prevention and control program: standard and transmission-based precautions, surveillance of infections in patients and staff as part of QAPI, reporting of reportable diseases to the Louisiana Office of Public Health in the time frames the Sanitary Code sets, employee health, cleaning of equipment, and infection control education for staff, patients and caregivers.","inShort":["Clean your hands before and after every patient contact.","Use gloves, gowns, masks and eye protection when you may touch blood or body fluids.","Tell the RN about any sign of infection in a patient.","If you have a fever, vomiting, diarrhea or a cough, call your supervisor before visiting patients.","Clean shared equipment between patients and teach patients and families how to prevent infection."],"primaryCitation":"42 CFR §484.70","citations":["LAC 48:I §9103.C.4.d","LAC 48:I §9103.C.8.a","LAC 48:I §9103.B.2.e","LAC 48:I §9119.A.4","LAC 48:I §9119.A.10","LAC 48:I §9115.B.1.o","LAC 51:II.105","LAC 51:II.107"],"federalCitations":["42 CFR §484.70","42 CFR §484.65"],"surveyorAsks":["Show me your infection surveillance log and how infections were followed up in QAPI.","How do your staff practice hand hygiene and bag technique in the home?","How and how fast would you report a case of a reportable disease?","Show me the infection control education you gave this patient and caregiver.","Who is responsible for the infection control program?"],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"LA-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.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}]],[["Authority"],["Adopted under LAC 48:I §9103.B.2.e, §9103.C.4.d and C.8.a, §9115.B.1.o and §9119.A.4 and A.10, issued under R.S. 40:2116.31 et seq.; the Louisiana Sanitary Code, LAC 51:II.105 and 107. The Agency applies 42 CFR §484.70 to every patient as its own standard; it is binding if the Agency is Medicare-certified."]],[["Applies to"],["Every employee and contractor who visits patients, the clinical manager, and office staff who handle supplies or employee health records."]],[["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 LA-HH-IC-02). Sharps and medical waste (Policy LA-HH-IC-03). Annual employee health screening content (Policy LA-HH-HR-02). Emergency plans for infectious disease emergencies (Policy LA-HH-EP-01)."]],[["Review"],["Reviewed at least once a year by the document owner and approved by the governing body, because LAC 48:I §9115.B.1.i requires policies and procedures that are \"written, current, and annually reviewed by appropriate personnel\" and §9102.B.1 requires the governing body's annual documented review of the policies and procedures. Also reviewed within 30 days of any amendment to a rule cited at Section 17 (the 30-day period is the Agency's own standard). Each review is recorded at Section 20 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 at least six years, as the Agency's own standard."]],[["Distribution"],["Master copy held in the policy manual at the Agency office at ",{"k":"field","name":"agency.address","text":"100 Example Street, Suite 100, Baton Rouge, Louisiana 70801"},". Available to every staff member it applies to, including staff of any branch office, through the policy library, and covered at orientation."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(225) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy prevents the spread of infections and communicable diseases among patients of ",{"k":"field","name":"agency.name","text":"Sample Agency, LLC"}," (the \"Agency\"), their families and Agency staff, and makes sure infections are found, tracked, reported and acted on."],"edited":false},{"heading":"2. Scope","body":["This policy covers program leadership, standard and transmission-based precautions, surveillance, reportable disease reporting, employee health, cleaning and disinfection of equipment, supplies, outbreak response, and education."],"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":[[["Patient"],["A person accepted for care by the Agency. LAC 48:I Chapter 91 and 42 CFR Part 484 both say \"patient\". Other Louisiana laws cited in this manual say \"individual\", \"consumer\" or \"adult\". In this policy these words mean the same person."]],[["Medicare-certified"],["Certified by CMS to take part in Medicare under 42 CFR Part 484, with the Louisiana Department of Health, Health Standards Section acting as the state survey agency. Where this policy says a duty applies \"if the Agency is Medicare-certified\", the duty is a federal Condition of Participation. The Louisiana licensing standards in LAC 48:I Chapter 91 apply to the Agency in every case."]],[["Clinical manager"],["The registered nurse \"designated in writing to supervise all aspects of patient care, all activities of professional staff and allied health personnel, and be responsible for compliance with regulatory requirements\" (LAC 48:I §9101). In this manual the clinical manager is ",{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"}," and the registered nurse designated in writing to act in the clinical manager's absence is ",{"k":"field","name":"people.alternateSupervisingNurse.name","text":"Casey Sample, RN"},". If the Agency is Medicare-certified, the same person is also the clinical manager under 42 CFR §484.105(c)."]],[["Standard precautions"],["The basic infection prevention practices used for every patient: hand hygiene; use of gloves, gowns, masks and eye protection based on expected exposure; respiratory hygiene and cough etiquette; safe injection practices; safe handling of sharps; and cleaning and disinfection of equipment and surfaces."]],[["Transmission-based precautions"],["Extra precautions (contact, droplet or airborne) used in addition to standard precautions for a patient known or suspected to have an infection spread in those ways."]],[["Reportable disease"],["\"any disease or condition for which an official report is required by the state health officer\" (LAC 51:II.101)."]],[["Surveillance"],["The ongoing, systematic collection and review of information about infections in patients and staff, to find problems and measure improvement."]]]},"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. It follows accepted standards of practice, including standard precautions; 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 QAPI program, with a method for identifying problems and a plan for actions expected to result in improvement and disease prevention; and provides infection control education to staff, patients and caregivers (42 CFR §484.70(a) to (c)). Chapter 91 has no separate infection control section, so the Agency adopts §484.70 for every patient as its own standard; it is binding if the Agency is Medicare-certified.\n\nThe clinical manager supervises the employee health program (LAC 48:I §9103.B.2.e) and leads this program. Basic infection control is part of aide training and annual aide in-service (§9103.C.4.d and C.8.a.iii), and the Agency's personnel policies set out specifications for employee health and safety (§9119.A.10). Staff report reportable diseases and conditions as the Louisiana Sanitary Code requires (LAC 51:II.105)."],"edited":false},{"heading":"5. Program Leadership","body":[],"list":[["The clinical manager, ",{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", is responsible for the program, including policies, surveillance, education, employee health and reporting. The alternate clinical manager acts in the clinical manager's absence."],["The program is reviewed at least once a year and whenever guidance from the Centers for Disease Control and Prevention (CDC) or the Louisiana Office of Public Health changes in a way that affects home care."],["Infection data are reported to the QAPI program each quarter (LAC 48:I §9131; Policy LA-HH-QA-01)."]],"ordered":false,"edited":false},{"heading":"6. Standard Precautions in the Home","body":[],"list":[["Hand hygiene: on arrival, before and after patient contact, before a clean or aseptic task, after contact with body fluids, after removing gloves, after touching the patient's surroundings, and before leaving. Use alcohol-based hand rub unless hands are visibly soiled, then soap and water and a disposable towel."],["Personal protective equipment: gloves for contact with blood, body fluids, mucous membranes or non-intact skin; gowns, masks and eye protection when splashes or sprays are possible. The Agency supplies protective equipment at no cost to staff (Policy LA-HH-IC-02)."],["Respiratory hygiene: staff with respiratory symptoms do not visit patients until cleared (Section 10); patients and family with coughs are offered masks and taught cough etiquette."],["Safe injection practices: one needle, one syringe, one time; single-dose vials for one patient only; never re-enter a vial with a used syringe."],["Sharps: used sharps go straight into a sharps container; needles are never recapped by hand (Policies LA-HH-IC-02 and LA-HH-IC-03)."],["Bag technique: the nursing bag is placed on a clean barrier in a clean area away from pets and children; hands are cleaned before reaching into the bag; soiled items never go back into the bag."]],"ordered":false,"edited":false},{"heading":"7. Transmission-Based Precautions","body":[],"list":[["When a patient is known or suspected to have an infection spread by contact, droplets or air (for example C. difficile, a multidrug-resistant organism, influenza or tuberculosis), the RN writes the precautions in the plan of care and the aide care instructions."],["Staff use the protective equipment the precaution needs. Fit-tested N95 respirators are used for airborne precautions where the Agency's respiratory protection program provides them."],["Patients on precautions are scheduled, where possible, as the last visit of the day, and reusable equipment stays in the home or is cleaned and disinfected before leaving."],["The family is taught how to protect themselves and others (Section 13)."]],"ordered":false,"edited":false},{"heading":"8. Surveillance","body":[],"list":[["Staff tell the RN of any sign of infection in a patient (for example fever, wound drainage or redness, urinary symptoms, cough, diarrhea) and of any new diagnosis of an infection."],["The RN reports the infection to the authorized healthcare provider and records it on Form LA-HH-IC-01-A: the patient, the type and site of infection, the date of onset, any device involved (urinary catheter, intravenous line, wound), any organism identified, whether the patient was hospitalized, and the action taken."],["The clinical manager uses written definitions, chosen from current national home care surveillance guidance, to decide whether an infection began during the Agency's care, so that counts are consistent from month to month."],["Staff illnesses that may be transmissible, and staff exposures, are logged in the confidential employee health file (Section 10)."],["Each month the clinical manager reviews the log for clusters, patterns by device, discipline, staff member or area, and possible outbreaks. Each quarter the results, rates and actions go to the QAPI program, which sets improvement actions and checks that they work (42 CFR §484.70(b) and §484.65)."]],"ordered":true,"edited":false},{"heading":"9. Reporting Reportable Diseases and Outbreaks","body":["The Louisiana Sanitary Code makes it the duty of every nurse, nurse practitioner, physician assistant, social worker and other health care professional \"to report a positive laboratory result or a confirmed or suspected case of any reportable disease or condition\" that he or she has examined or evaluated, is attending, or has knowledge of (LAC 51:II.105.C). The list of reportable diseases is set by the state health officer and may change (LAC 51:II.103), so the clinical manager checks the current list before each report."],"table":{"caption":["Louisiana reporting classes (LAC 51:II.105.D)"],"headers":[["Class"],["Time frame in the rule"],["Examples from the rule"]],"rows":[[["Class A"],["Immediately upon recognition, by telephone (or another electronic format acceptable to the Office of Public Health), and no later than 24 hours from recognition. Outbreaks of any infectious disease, unusual clusters, rare or exotic communicable diseases and unexplained deaths are reported the same way."],["Carbapenem-resistant Acinetobacter and Enterobacteriaceae; Candida auris; COVID-19; measles; invasive Neisseria meningitidis; outbreaks of any infectious diseases"]],[["Class B"],["Within one business day"],["As listed in §105.D.2"]],[["Class C"],["Within five business days"],["As listed in §105.D.3"]],[["Class D"],["Within five business days"],["As listed in §105.D.4"]],[["Class E (occupational)"],["Within 10 business days"],["Occupationally related diseases or conditions"]]]},"note":["Reports go to ",{"k":"field","name":"fixed.diseaseReportRoute","text":"Louisiana Department of Health, Office of Public Health, Infectious Disease Epidemiology: the regional epidemiologist during business hours (section phone 504-568-8313); the on-call epidemiologist at 1-800-256-2748 during non-business hours, weekends and holidays"},". The staff member who learns of the case tells the clinical manager at once; the clinical manager makes or confirms the report within the time frame and records the date, time, person spoken to and any instructions in the employee health file or patient record. A report by the patient's physician or a laboratory does not stop the Agency from reporting what it knows. Laboratories and applicable healthcare facilities have their own reporting duty under LAC 51:II.107."],"edited":false},{"heading":"10. Employee Health","body":[],"list":[["Each employee has an annual health screening in accordance with current local, federal and state laws (LAC 48:I §9119.A.4; Policy LA-HH-HR-02)."],["Staff with fever, vomiting, diarrhea, a draining skin lesion, conjunctivitis, a new rash, or respiratory symptoms tell their supervisor before their first visit and do not visit patients until the clinical manager clears them, following current CDC guidance for health care personnel (Agency standard)."],["Hepatitis B vaccination is offered under Policy LA-HH-IC-02. The Agency encourages staff to receive other vaccines CDC recommends for health care personnel, such as seasonal influenza vaccine, and records the vaccines staff report."],["Employee health records are kept confidential and separate from personnel files."]],"ordered":false,"edited":false},{"heading":"11. Cleaning and Disinfection of Equipment and Supplies","body":[],"list":[["Reusable equipment that goes from home to home (for example blood pressure cuffs, stethoscopes, thermometers, pulse oximeters, scales and glucose meters) is cleaned and disinfected after each patient with an EPA-registered disinfectant, following the manufacturer's instructions and contact times, or assigned to a single patient."],["Equipment that cannot be cleaned is single-patient use."],["Clean and sterile supplies are stored in closed containers in the vehicle, off the floor, away from soiled items, and protected from heat and moisture. Expired or damaged supplies are discarded."],["Agency premises, including any supply room, are kept clean; soiled items are kept separate from clean items."]],"ordered":false,"edited":false},{"heading":"12. Outbreaks and Emerging Infectious Diseases","body":[],"list":[["If the clinical manager suspects an outbreak (a cluster of the same infection in patients or staff), it is reported as a Class A event (Section 9) and the clinical manager follows the Office of Public Health's instructions."],["The Agency keeps a supply of protective equipment and hand hygiene products, and plans for staffing and patient prioritization during an epidemic or pandemic as part of its emergency preparedness program (Policy LA-HH-EP-01)."]],"ordered":false,"edited":false},{"heading":"13. Education","body":[],"list":[["Staff: infection control at orientation and at least once a year; for aides, basic infection control procedures are part of aide training and at least part of the 12 hours of annual in-service (LAC 48:I §9103.C.4.d and C.8.a.iii; Policy LA-HH-AID-01)."],["Patients and caregivers: hand hygiene; care of wounds, catheters, lines or other devices the patient uses; signs of infection and when to call; safe handling of soiled dressings and sharps (Policy LA-HH-IC-03); cleaning of the patient's own equipment; and respiratory etiquette. Education is given in a language and manner the patient understands and is documented in the clinical record (42 CFR §484.70(c))."]],"ordered":false,"edited":false},{"heading":"14. 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"}],["Leads the program; keeps the surveillance log; reports reportable diseases; clears ill staff to return; reports to QAPI. In the clinical manager's absence, ",{"k":"field","name":"people.alternateSupervisingNurse.name","text":"Casey Sample, RN"},", ",{"k":"field","name":"people.alternateSupervisingNurse.title","text":"Alternate Supervising Nurse"}," acts."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Provides protective equipment, disinfectants and supplies; supports the program with resources."]],[["All clinical staff"],["Follow standard and transmission-based precautions; report infections and exposures; educate patients and caregivers; clean equipment."]],[["All staff"],["Stay home when ill as Section 9 requires; report illness to the supervisor."]]]},"edited":false},{"heading":"15. Records and Compliance Monitoring","body":["Form LA-HH-IC-01-A, disease reports and outbreak records are kept by the clinical manager for at least six years, as the Agency's own standard; employee health records are kept as Policy LA-HH-HR-02 and Policy LA-HH-IC-02 require. Patient education is documented in the clinical record. The quarterly QAPI report includes infection rates, trends and actions (Policy LA-HH-QA-01)."],"edited":false},{"heading":"16. Staff Training","body":["All patient care staff complete infection control training at orientation (Policy LA-HH-HR-01) and at least once a year. Training covers hand hygiene, protective equipment, bag technique, cleaning of equipment, transmission-based precautions, recognizing infections, and how to report a reportable disease."],"edited":false},{"heading":"17. References","body":["This policy implements the following authorities."],"list":[["42 CFR §484.70, Infection prevention and control (Agency standard for every patient; binding if Medicare-certified)"],["42 CFR §484.65, Quality assessment and performance improvement (if Medicare-certified)"],["LAC 48:I §9103.B.2.e, Clinical manager supervises the employee health program"],["LAC 48:I §9103.C.4.d and C.8.a.iii, Aide training and in-service in infection control"],["LAC 48:I §9115.B.1.o, Protect the patient from unsafe clinical practices"],["LAC 48:I §9119.A.4 and A.10, Annual employee health screening; employee health and safety"],["LAC 51:II.101 to 107, Louisiana Sanitary Code: disease reporting requirements"]],"ordered":false,"edited":false},{"heading":"18. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Policy LA-HH-IC-02"],["Bloodborne Pathogens Exposure Control Plan"]],[["Policy LA-HH-IC-03"],["Sharps, Medical Waste, and Patient and Caregiver Instruction"]],[["Policy LA-HH-HR-02"],["Personnel Records and Annual Employee Health Screening"]],[["Policy LA-HH-AID-01"],["Home Health Aide Qualifications, Training, Competency, and In-Service"]],[["Policy LA-HH-QA-01"],["Quality Assessment and Performance Improvement and Quarterly Clinical Record Review"]],[["Policy LA-HH-EP-01"],["Emergency Preparedness Plan and Program"]],[["Policy LA-HH-CS-05"],["Laboratory Services, Specimen Collection, and Waived Testing"]],[["Policy LA-HH-MED-01"],["Medication Management, Medication Errors, and Drug Regimen Review"]],[["Form LA-HH-IC-01-A"],["Infection Surveillance Log"]]]},"edited":false},{"heading":"19. 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":"20. 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 17 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"la-hha","state":"Louisiana","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}}