{"ref":"TX-HSP-IC-01","title":"Infection Prevention and Control Program and Medical Waste","category":"Infection control","own":false,"summary":"Sets out the Agency’s infection prevention and control program: standard and transmission-based precautions, staff health, surveillance and the patient infection log, reporting of notifiable conditions, infection control education for staff, volunteers, patients and families, and the safe handling and disposal of medical waste and sharps.","inShort":["Clean your hands before and after every patient contact and after removing gloves.","Use standard precautions with every patient, and the extra precautions in the plan of care when they are listed.","Do not make visits when you have a fever, vomiting, diarrhea or another illness that can spread. Tell the scheduler.","Report any sign of infection in a patient to the RN the same day. The RN records it on the infection log.","Put sharps in a sharps container right after use, and give patients who use sharps both spoken and written disposal instructions."],"primaryCitation":"42 CFR §418.60","citations":["26 TAC §558.853","26 TAC §558.285","26 TAC §558.286","26 TAC §558.303(2)","Tex. Health & Safety Code ch. 81","Tex. Health & Safety Code ch. 85, subch. I","25 TAC ch. 1, subch. K"],"federalCitations":["42 CFR §418.60","29 CFR §1910.1030"],"surveyorAsks":["Show me your infection log. What did you do about the trend you found?","How is infection control part of your QAPI program?","Show me the written sharps disposal instructions you gave this patient, and where you documented telling them.","What infection control education do you give volunteers and families?","Watch this nurse’s bag technique and hand hygiene during the visit."],"version":"1.0","effectiveDate":"2026-10-01","reviewDate":"2027-10-01","approvedBy":"Pat Sample, Administrator","forms":[{"ref":"TX-HSP-IC-01-A","title":"Patient Infection 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 Hospice, LLC"}]],[["Document owner"],[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"},", as infection control lead"]],[["Authority"],["Adopted under 26 TAC §558.853 (hospice infection control), §558.285 (infection control) and §558.286 (special or medical waste). If the Agency is Medicare-certified, also 42 CFR §418.60."]],[["Applies to"],["Every employee, volunteer and contractor, in patients’ homes, facilities, the office and vehicles, and the patients, families and caregivers the Agency teaches."]],[["Status"],["Mandatory."]],[["Not covered here"],["The bloodborne pathogens exposure control plan, hepatitis B vaccination and post-exposure follow-up (Policy TX-HSP-IC-02). Infectious disease emergencies and pandemics (Policy TX-HSP-EP-01). The QAPI program as a whole (Policy TX-HSP-QA-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 15. Each review is recorded at Section 18."]],[["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; available to every staff member it applies to through the policy library, and covered at orientation."]],[["Questions"],["Direct to the document owner on ",{"k":"field","name":"agency.phone","text":"(512) 555-0100"}," or ",{"k":"field","name":"agency.email","text":"office@example.com"},"."]]]},"edited":false},{"heading":"1. Purpose","body":["This policy makes sure that ",{"k":"field","name":"agency.name","text":"Sample Hospice, LLC"}," (the \"Agency\") maintains and documents an effective infection control program that protects patients, families, visitors and Agency personnel by preventing and controlling infections and communicable diseases (26 TAC §558.853(a); 42 CFR §418.60), and that it meets the Texas requirements for infection control policies, infection documentation and medical waste (26 TAC §§558.285-558.286)."],"edited":false},{"heading":"2. Scope","body":["This policy applies to all care and services the Agency provides, in every setting, and to all supplies, equipment and waste the Agency handles."],"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 receiving hospice services. 26 TAC Chapter 558 says \"client\" (26 TAC §558.2(28)) and 42 CFR Part 418 says \"patient\"; in this policy they mean the same person. \"Family\" includes the people the patient considers family and the primary caregiver."]],[["Standard precautions"],["The infection prevention practices used for every patient, whatever their diagnosis, based on treating all blood, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes as potentially infectious: hand hygiene, personal protective equipment (PPE), respiratory hygiene, safe injection practices, safe handling of sharps and cleaning of equipment and surfaces."]],[["Transmission-based precautions"],["Contact, droplet and airborne precautions used in addition to standard precautions for patients known or suspected to have certain infections, as current Centers for Disease Control and Prevention (CDC) guidance recommends."]],[["Infection acquired while receiving services"],["An infection that a patient develops after admission to the Agency and that was not present or incubating at admission, such as a urinary tract infection in a patient with a catheter, a wound infection or pneumonia."]],[["Sharps"],["Hypodermic needles, hypodermic syringes with attached needles, scalpel blades, razor blades, disposable razors, disposable scissors used in medical procedures, and intravenous stylets and rigid introducers (26 TAC §558.286(b))."]],[["Special waste from health care-related facilities"],["Medical waste as defined in 25 TAC Chapter 1, Subchapter K, such as sharps and items saturated with blood."]]]},"edited":false},{"heading":"4. Policy Statement (26 TAC §558.853; §558.285; 42 CFR §418.60)","body":["The Agency maintains and documents an effective infection control program that protects patients, families, visitors and Agency personnel by preventing and controlling infections and communicable diseases (26 TAC §558.853(a); 42 CFR §418.60). The Agency:"],"list":[["follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions (26 TAC §558.853(b); 42 CFR §418.60(a));"],["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, and that includes a method of identifying infectious and communicable disease problems and a plan for implementing appropriate actions expected to result in improvement and disease prevention (26 TAC §558.853(c); 42 CFR §418.60(b));"],["provides infection control education to employees, volunteers, contract staff, patients, and family members and other caregivers (26 TAC §558.853(d); 42 CFR §418.60(c));"],["ensures that the Agency, its employees and its contractors comply with Texas Health and Safety Code Chapter 81 (communicable diseases), the OSHA Bloodborne Pathogens standard at 29 CFR §1910.1030 and its Appendix A, and Texas Health and Safety Code Chapter 85, Subchapter I, concerning the prevention of the transmission of HIV and hepatitis B virus (26 TAC §558.285(1)); and"],["documents infections that patients acquire while receiving services (26 TAC §558.285(2)(A)), and handles biohazardous waste and sharps safely (26 TAC §558.286)."]],"ordered":false,"edited":false},{"heading":"5. Leadership of the Program","body":["The supervising nurse leads the infection control program, or designates in writing an RN with infection prevention training to do so. The lead keeps the program current with CDC guidance, reviews infection data monthly, reports to the QAPI Committee at least quarterly, and advises staff on precautions for individual patients. This structure is the Agency’s standard."],"edited":false},{"heading":"6. Standard and Transmission-Based Precautions","body":[],"list":[["Hand hygiene. Staff clean their hands with an alcohol-based hand rub, or soap and water when hands are visibly soiled or after caring for a patient with diarrhea, before and after patient contact, before a clean or sterile task, after contact with body fluids, after removing gloves, and after touching the patient’s surroundings."],["PPE. Gloves, gowns, masks, respirators and eye protection are supplied at no cost and worn according to the task and the precautions in place, and removed and discarded before leaving the patient’s room or home."],["Respiratory hygiene. Staff with respiratory symptoms do not make visits (Section 7). Patients and families 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; no reuse of sharps."],["Bag technique. The nursing bag is placed on a clean barrier or kept in the car, hands are cleaned before going into the bag, and no used item goes back into the bag unless it has been cleaned and disinfected."],["Equipment. Reusable equipment such as stethoscopes and blood pressure cuffs is cleaned and disinfected with an EPA-registered disinfectant after each patient, according to the product’s contact time. Single-patient items stay in the home."],["Transmission-based precautions. When a patient has or may have an infection that needs contact, droplet or airborne precautions, the RN case manager records the precautions in the plan of care and on the aide care instructions, and the Agency supplies the PPE needed."],["Devices. Staff follow the Agency’s procedure manual for urinary catheters, intravenous lines, wounds and feeding tubes to reduce infection risk."]],"ordered":false,"edited":false},{"heading":"7. Staff Health","body":[],"list":[["Staff who have a fever, vomiting, diarrhea, a draining skin lesion, conjunctivitis or a communicable illness tell the scheduler before visiting and do not make visits until they meet the CDC return-to-work guidance the infection control lead applies."],["The Agency offers influenza vaccine to employees each year and may give it under a physician’s standing order meeting 26 TAC §558.303(2). Hepatitis B vaccination is offered under Policy TX-HSP-IC-02."],["As the Agency’s standard, following CDC recommendations for health care personnel, staff with patient contact receive baseline tuberculosis screening before their first patient contact."],["Staff who have an exposure to blood or body fluids follow Policy TX-HSP-IC-02."]],"ordered":false,"edited":false},{"heading":"8. Surveillance and the Patient Infection Log","body":[],"list":[["Any staff member who notices signs or symptoms of an infection reports it to the RN case manager the same day. The RN assesses the patient, tells the practitioner and obtains orders."],["The RN records each infection the patient acquires while receiving services on Form TX-HSP-IC-01-A. The record includes the date the infection was detected, the patient’s name, primary diagnosis, signs and symptoms, type of infection, pathogens identified and treatment (26 TAC §558.285(2)(A))."],["The infection control lead reviews the log each month for trends by infection type, device, staff member and setting, and investigates any cluster."],["Findings and actions are reported to the QAPI Committee, which approves a plan for implementing actions expected to result in improvement and disease prevention, and tracks whether they work (26 TAC §558.853(c); Policy TX-HSP-QA-01)."],["An outbreak, or a communicable disease affecting several patients or staff, is reported to the Administrator at once and may be handled under Policy TX-HSP-EP-01."]],"ordered":true,"edited":false},{"heading":"9. Reporting Notifiable Conditions","body":["Texas Health and Safety Code Chapter 81 and the Department of State Health Services (DSHS) rules require certain diseases and conditions to be reported to the local health authority or DSHS, within the time frame DSHS sets for each condition. When an Agency nurse learns that a patient has a notifiable condition that has not already been reported by a physician or laboratory, the nurse tells the infection control lead the same day, and the lead checks the current DSHS list and makes any report required. The report is recorded on the infection log."],"edited":false},{"heading":"10. Infection Control Education","body":["The Agency provides infection control education to employees, volunteers, contract staff, patients, and family members and other caregivers (26 TAC §558.853(d); 42 CFR §418.60(c))."],"list":[["Employees and contract staff: at orientation, at least yearly, and when guidance changes, covering this policy, hand hygiene, PPE, precautions, cleaning, waste and sharps, and Policy TX-HSP-IC-02."],["Volunteers: at orientation, covering hand hygiene, when not to visit, and what not to touch (Policy TX-HSP-VOL-01)."],["Patients, families and caregivers: at admission and when needs change, covering hand hygiene, care of devices, cleaning, laundry, safe disposal of dressings and sharps, and signs of infection to report. The teaching is recorded."]],"ordered":false,"edited":false},{"heading":"11. Medical Waste and Sharps (26 TAC §558.286)","body":["This section is the Agency’s written policy for the safe handling and disposal of biohazardous waste and materials (26 TAC §558.286(a))."],"list":[["Special or medical waste that the Agency generates while providing care is disposed of according to 25 TAC Chapter 1, Subchapter K (26 TAC §558.286(b)). Agency sharps containers and regulated waste are returned to the office in a closed, labeled, puncture-resistant container carried in the trunk or cargo area, and collected by the Agency’s licensed medical waste contractor."],["Sharps are placed in a puncture-resistant, leak-proof, labeled sharps container immediately after use. Containers are replaced when about three-quarters full, as the Agency’s standard, and are never overfilled."],["The Agency gives every patient who uses sharps at home both verbal and written instructions on the proper procedure for disposing of sharps (26 TAC §558.286(b)). The nurse records that both were given."],["Soiled dressings and incontinence products that are not saturated with blood are bagged securely and placed in the household trash. Items saturated with blood are handled as regulated waste."],["Spills of blood or body fluids are cleaned with gloves and an EPA-registered disinfectant, following Policy TX-HSP-IC-02."]],"ordered":false,"edited":false},{"heading":"12. Responsibilities","body":["Accountability under this policy is allocated as follows."],"table":{"caption":null,"headers":[["Role"],["Responsibility"]],"rows":[[["Governing body"],["Adopts this policy and supplies the resources the program needs."]],[[{"k":"field","name":"people.supervisingNurse.name","text":"Robin Sample, RN"},", ",{"k":"field","name":"people.supervisingNurse.title","text":"Supervising Nurse"}],["Owns this policy and leads the program, or designates the RN who does."]],[[{"k":"field","name":"people.administrator.name","text":"Pat Sample"},", ",{"k":"field","name":"people.administrator.title","text":"Administrator"}],["Makes sure PPE, supplies and the medical waste contract are in place, and that outbreaks are escalated."]],[["QAPI Committee"],["Reviews infection data and approves improvement actions."]],[["RN case managers"],["Assess and document infections, set precautions in the plan of care, and teach families."]],[["All staff, volunteers and contractors"],["Follow standard and transmission-based precautions, report infections and their own illness, and complete education."]]]},"edited":false},{"heading":"13. Records and Compliance Monitoring","body":["The patient infection log, infection reports, notifiable condition reports, teaching records and sharps instructions are kept in the patient record or the infection control file (Policy TX-HSP-REC-01). Education records are kept in the personnel and volunteer files. Each quarter, as the Agency’s standard, the infection control lead reports to the QAPI Committee on:"],"list":[["infections acquired while receiving services, by type, with rates where numbers allow;"],["investigations and the actions taken and their results;"],["hand hygiene and bag technique observed during supervisory and competency visits; and"],["completion of staff, volunteer and family education."]],"ordered":false,"edited":false},{"heading":"14. Staff Training","body":["Training is delivered and recorded as follows. Frequencies marked as the Agency’s standard are not set by rule."],"table":{"caption":null,"headers":[["Who"],["Content"],["When"],["Record"]],"rows":[[["All employees and contract staff"],["Section 10 content and this policy"],["At orientation, at least every 12 months as the Agency’s standard, and when guidance changes"],["Training log"]],[["Volunteers"],["Hand hygiene, illness and visiting, what not to touch"],["At orientation"],["Volunteer training record"]],[["Nurses and aides"],["Bag technique, PPE donning and removal, device care"],["At orientation and at competency checks"],["Competency record"]]]},"edited":false},{"heading":"15. References","body":["This policy implements the following authorities."],"list":[["26 Texas Administrative Code §558.853, Hospice Infection Control"],["26 Texas Administrative Code §558.285, Infection Control"],["26 Texas Administrative Code §558.286, Disposal of Special or Medical Waste"],["26 Texas Administrative Code §558.303(2), Vaccines and tuberculin"],["Texas Health and Safety Code Chapter 81, Communicable Diseases"],["Texas Health and Safety Code Chapter 85, Subchapter I, prevention of the transmission of HIV and hepatitis B virus"],["25 Texas Administrative Code Chapter 1, Subchapter K, Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities"],["42 CFR §418.60, Infection control"],["29 CFR §1910.1030, Bloodborne Pathogens"]],"ordered":false,"edited":false},{"heading":"16. Related Policies and Forms","body":["The following documents are read together with this policy."],"table":{"caption":null,"headers":[["Reference"],["Title"]],"rows":[[["Form TX-HSP-IC-01-A"],["Patient Infection Log"]],[["Policy TX-HSP-IC-02"],["Bloodborne Pathogens Exposure Control Plan"]],[["Policy TX-HSP-QA-01"],["Quality Assessment and Performance Improvement"]],[["Policy TX-HSP-EP-01"],["Emergency Preparedness Program"]],[["Policy TX-HSP-VOL-01"],["Volunteer Program"]],[["Policy TX-HSP-HR-01"],["Staffing, Orientation, Competency and In-Service Training"]],[["Policy TX-HSP-MED-01"],["Drugs and Biologicals: Ordering, Drug Management Review, Labeling and Safe Use"]],[["Policy TX-HSP-NUR-01"],["Nursing Services and Nursing Practice"]],[["Policy TX-HSP-AIDE-01"],["Hospice Aide and Homemaker Services"]],[["Policy TX-HSP-REC-01"],["Clinical Records, Retention and Patient List"]]]},"edited":false},{"heading":"17. Approval","body":["This policy is adopted by the governing body of ",{"k":"field","name":"agency.name","text":"Sample Hospice, 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":"18. 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 15 is amended, the amendment is recorded in this table and a new version of this policy is issued."],"edited":false}],"missing":[],"editedCount":0,"pack":"tx-hospice","state":"Texas","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 Hospice","legalName":"Sample Hospice, LLC","logo":null}}