Infection Prevention and Control, Communicable Disease Reporting, and Outbreak Reporting

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.

Patients at home are often frail, and staff travel from home to home. This policy sets out how the Agency prevents the spread of infection, finds infections early, reports the diseases California requires to be reported, and teaches patients and families to protect themselves.

This policy covers every visit, every piece of equipment staff carry or use, the parent office and branch offices, and every patient, family member, caregiver, and staff member the Agency serves or employs.

For the purposes of this policy, the following terms have the meanings below. The California home health agency regulations (22 CCR Division 5, Chapter 6) and 42 CFR Part 484 both say "patient", and this policy uses the same word for the person receiving home health services.

The Agency’s administrative policies include "Policies designed to prevent, identify, and control infections." (22 CCR §74721(c)(4)). This policy, with Policies CA-HH-IC-02, CA-HH-IC-03, and CA-HH-HR-03, is those policies. The Agency follows the two reporting rules in its license regulations: "All cases of reportable diseases shall be reported to the local health officer in accordance with Section 2500, Article 1, Subchapter 1, Title 17, California Administrative Code." (22 CCR §74725), and "All cases of any outbreak or undue prevalence of infections or parasitic disease or infestation shall be reported to the local health officer in accordance with Section 2502, Article 1, Subchapter 4, Title 17, California Administrative Code." (22 CCR §74727). The Agency has a written policy on employees who develop or sustain symptoms of infectious diseases (22 CCR §74723(e); Policy CA-HH-HR-03). The infection control program is evaluated at least annually as part of the evaluation of overall agency functioning (22 CCR §74742(c)(3)).

If the Agency is Medicare-certified, it maintains and documents an infection control program whose goal is the prevention and control of infections and communicable diseases; 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 the QAPI program, with a method for identifying problems and a plan for actions expected to improve and prevent disease; and provides infection control education to staff, patients, and caregivers (42 CFR §484.70(a)-(c)). The Agency runs the program this way for every patient, as the Agency’s own standard.

The cross-reference in 22 CCR §74727 is to an older numbering of Title 17. In the current 17 CCR, §2502 sets out the reports local health officers send to the State Department of Public Health, and the duty to report "OUTBREAKS of ANY DISEASE" immediately by telephone is in the list in 17 CCR §2500(j). The Agency reports outbreaks under §2500 and so meets §74727.

• The infection prevention lead (the DPCS, or a registered nurse the DPCS designates in writing) coordinates the program, keeps this policy current with guidance from the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health, and reports to the Administrator and to the quality management program.
• The program covers prevention (Sections 6 to 8), surveillance (Section 9), reporting (Section 10), outbreaks (Section 11), education (Section 12), and staff health (Policy CA-HH-HR-03).
• Supplies needed to follow this policy (hand sanitizer, gloves, gowns, masks, eye protection, respirators where Policy CA-HH-IC-02 requires them, disinfectant, and barriers) are provided to staff at no cost, as the Agency’s own standard.

• Perform hand hygiene on arrival, before and after touching the patient, before any clean or aseptic procedure, after any contact with blood or body fluids, after touching the patient’s surroundings, after removing gloves, and before leaving the home.
• Use alcohol-based hand rub unless hands are visibly soiled or the patient has, or may have, an infection that hand rub does not kill (for example, Clostridioides difficile or norovirus); then wash with soap and water.
• Wear gloves for contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items. Add a gown, mask, and eye protection when splashes or sprays are possible.
• Follow safe injection practices: one needle and one syringe for one use; never reuse single-dose vials on more than one occasion; use safety-engineered sharps (Policy CA-HH-IC-02).
• Ask patients and household members who are coughing to cover their cough and, where they can, wear a mask during the visit.

1. Place the visit bag on a clean, dry surface, on a barrier, away from children and pets. Never on the floor or bed.
2. Perform hand hygiene before opening the bag. Take out everything needed for the visit at once and place it on the barrier.
3. Close the bag. Do not reopen it during care unless hands are cleaned first.
4. After care, clean and disinfect any reusable item before returning it to the bag. Items that cannot be cleaned stay in the home or are discarded.
5. For a patient on transmission-based precautions, bring only what the visit needs, leave dedicated equipment in the home where possible, and see that patient last in the day when the schedule allows, as the Agency’s own standard.

• Reusable equipment that touches intact skin (for example, a blood pressure cuff, stethoscope, thermometer, pulse oximeter, or scale) is cleaned and disinfected after each patient with a disinfectant registered by the U.S. Environmental Protection Agency, used for the contact time on the label.
• Equipment that touches mucous membranes or non-intact skin, or enters sterile tissue, is single-use or reprocessed only as the manufacturer’s instructions require.
• Glucose meters are used for one patient only unless the manufacturer’s instructions allow and describe cleaning between patients (Policy CA-HH-CS-04).
• Equipment the Agency supplies is checked to be in good working order at each visit (22 CCR §74693(c); Policy CA-HH-MED-02).

The infection prevention lead keeps the Infection Surveillance and Reporting Log (Form CA-HH-IC-01-A) and reviews it each month, as the Agency’s own standard. Staff report to their supervisor the same day:

• Any new infection in a patient that may be linked to Agency care, such as a urinary tract infection in a patient with a catheter, an infected wound or surgical site, a bloodstream or catheter-site infection in a patient with a central line, or pneumonia.
• Any patient with a multidrug-resistant organism, Candida auris, or another organism CDPH or the local health officer has asked providers to watch for.
• Any patient or staff member with a communicable disease that could spread through the Agency’s visits, including influenza, COVID-19, tuberculosis, scabies, or gastrointestinal illness.
• Any cluster: two or more patients or staff with a similar illness linked by time, place, or staff member.

The lead looks for patterns by staff member, team, procedure, and device, and reports findings and actions to the quality management program (Policy CA-HH-QA-01) and, if the Agency is Medicare-certified, to the QAPI program (42 CFR §484.70(b); Policy CA-HH-QA-02).

Every health care provider knowing of or in attendance on a case or suspected case of a disease or condition listed in 17 CCR §2500(j) must report it to the local health officer for the jurisdiction where the patient resides, and the administrator of a setting where more than one health care provider may know of a case must establish administrative procedures to assure reports are made (17 CCR §2500(b)-(c)). This section is that procedure for the Agency.

• The nurse who identifies a case or suspected case, or learns of one (for example, from a laboratory result or a hospital discharge summary), tells the infection prevention lead the same day, and at once for a disease reported immediately.
• The infection prevention lead checks the current list in 17 CCR §2500(j) and the local health department’s instructions, and makes the report for the Agency within the time in Table 1. The Agency does not wait for the physician or laboratory to report.
• The report includes the information in 17 CCR §2500(d)(1), if known, including the disease, dates of onset and diagnosis, the patient’s identifying and contact information, and the name, address, and telephone number of the person reporting. The local health department’s Confidential Morbidity Report form may be used (17 CCR §2500(e)).
• The report is a disclosure the Agency may make without the patient’s authorization (45 CFR §164.512(b); Policy CA-HH-PRV-01). It is recorded in the patient’s record and on Form CA-HH-IC-01-A.
• The Agency follows any instruction from the local health officer about investigation and control (17 CCR §2501).

1. Any staff member who suspects an outbreak (Section 9) tells the infection prevention lead at once.
2. The infection prevention lead reports the outbreak or undue prevalence of infection, parasitic disease, or infestation to the local health officer immediately by telephone (22 CCR §74727; 17 CCR §2500(j)), and tells the Administrator and the DPCS.
3. The DPCS puts control measures in place at once: transmission-based precautions, cohorting staff to affected patients where possible, extra cleaning, screening of staff and patients for symptoms, and removal of ill staff from patient contact (Policy CA-HH-HR-03).
4. The Agency follows the local health officer’s instructions and records each action and its date on Form CA-HH-IC-01-A.
5. When the outbreak is over, the infection prevention lead writes a short review of cause, response, and lessons for the quality management program.

Staff teach each patient and caregiver, at the start of care and when the plan changes, as the Agency’s own standard and, if the Agency is Medicare-certified, as 42 CFR §484.70(c) requires:

• Hand hygiene, and when to use gloves at home.
• How to care for catheters, wounds, tubes, and lines the patient has, and the signs of infection to report.
• Cough etiquette and keeping ill visitors away.
• Cleaning the home care area, handling soiled laundry, and safe disposal of dressings and sharps (Policy CA-HH-IC-03).
• Vaccinations the patient’s practitioner recommends.

Staff health assessments, tuberculosis screening, and the policy on employees who develop or sustain symptoms of infectious diseases, including when they are removed from patient contact, are in Policy CA-HH-HR-03 (22 CCR §74723). Hepatitis B vaccination, vaccinations required by the Cal/OSHA aerosol transmissible diseases standard, and exposure incidents are in Policy CA-HH-IC-02. A staff member with a reportable disease is reported under Section 10 when the Agency is a provider in attendance or otherwise required to report.

Each year the infection prevention lead presents a summary of surveillance data, reports made, outbreaks, staff exposures, training completed, and changes in guidance to the annual evaluation of overall agency functioning, which evaluates the infection control program (22 CCR §74742(c)(3); Policy CA-HH-QA-01). The DPCS revises this policy as the evaluation requires, and the patient care policy review group reviews it each year (Cal. Health & Safety Code §1727.5(d)).

Accountability under this policy is allocated as follows.

Form CA-HH-IC-01-A, reports to the local health officer, outbreak reviews, and annual summaries are kept by the infection prevention lead for at least seven years, as the Agency’s own standard. Reports about a patient are also recorded in the patient’s health record (Policy CA-HH-REC-01). Hand hygiene and bag technique are observed on supervisory visits and recorded on Form CA-HH-AID-02-B for aides, and on a sample of nurse visits each quarter, as the Agency’s own standard.

All staff with patient contact are trained on this policy at orientation and at least once a year, including hand hygiene, standard and transmission-based precautions, bag technique, equipment cleaning, and how to report an infection (Policy CA-HH-HR-01). The infection prevention lead is trained on 17 CCR §2500 and the local health department’s reporting methods.

This policy implements the following authorities.

• 22 CCR §74721(c)(4), Infection Control Policies
• 22 CCR §74725, Reportable Diseases
• 22 CCR §74727, Outbreaks
• 22 CCR §74723(e), Employees With Symptoms of Infectious Disease
• 22 CCR §74742(c)(3), Annual Evaluation of the Infection Control Program
• 17 CCR §2500, Reporting to the Local Health Authority
• 17 CCR §2501, Investigation by the Local Health Officer; 17 CCR §2502, Reports by the Local Health Officer
• 42 CFR §484.70, Infection Prevention and Control (if Medicare-certified)
• 45 CFR §164.512(b), Disclosures for Public Health Activities

The following documents are read together with this policy.

This policy is adopted by the governing body of 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.

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 18 is amended, the amendment is recorded in this table and a new version of this policy is issued.