Infection Prevention and Control Program 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.

This policy protects patients, families, visitors and staff from infections and communicable diseases by preventing their spread, finding problems early, reporting what the law requires, and acting on what is found.

This policy covers infection prevention and control in patients' homes, in facilities where patients live, in staff vehicles and at the Agency office.

The following terms have the meanings given below when used in this policy.

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), following accepted standards of practice, including standard precautions (§418.60(a)); maintaining a coordinated agency-wide program for surveillance, identification, prevention, control and investigation that is an integral part of QAPI (§418.60(b)); and providing infection control education to employees, contracted providers, patients, family members and other caregivers (§418.60(c)). The Agency's program also includes every element California lists for a hospice's infection control program (22 CCR §74880(d)(4)(B)(i)-(v); Table 1), and the Agency complies with Cal/OSHA's aerosol transmissible diseases standard, which applies to "Home health care" and to "Long term health care facilities and hospices" (8 CCR §5199(a)(1)(A)).

Table 1 shows each element California names and where the Agency meets it.

The DPCS (Robin Sample, RN) leads the program and is the administrator of the ATD Plan, knowledgeable in infection control principles and practices as they apply to home-based hospice (8 CCR §5199(d)(2)(A)). The DPCS reports infection control data to QAPI at least quarterly (Agency standard; Policy CA-HSP-QA-01), and the program's goals are part of the QAPI plan (42 CFR §418.60(b)(1)).

Every staff member uses standard precautions with every patient. Hands are cleaned with alcohol-based hand rub or soap and water before and after patient contact, before clean or sterile tasks, after contact with body fluids or contaminated surfaces, and after removing gloves; soap and water is used when hands are visibly soiled and after caring for a patient with diarrhea or known C. difficile (Agency standard). Staff carry hand rub, gloves, masks, gowns, eye protection and disposal bags in every visit bag.

Staff teach patients and households to cover coughs, use tissues and clean hands. Staff with symptoms of a respiratory infection do not make visits until cleared under Policy CA-HSP-HR-06; when visits must continue during community spread of a respiratory virus, staff wear masks as the ATD Plan directs.

Staff choose PPE for the task and the patient's known or suspected infection, and add contact, droplet or airborne precautions as the assigned registered nurse records in the plan of care. Cal/OSHA does not require engineering controls such as isolation rooms in settings where home health care or home-based hospice care is being provided (8 CCR §5199(e)(4)-(5)), but staff must use a respirator, at least as effective as an N95 filtering facepiece respirator, when working in a residence where an AirID case or suspected case is known to be present (8 CCR §5199(g)(3)(A), (g)(4)(E)). Every employee who may need a respirator is in the Agency's respiratory protection program and passes a fit test at initial fitting, when a different respirator is used, and at least annually (8 CCR §5199(g)(2), (g)(6)(B)).

The visit bag is placed on a clean barrier, never on the floor, and opened only after hand hygiene. Reusable equipment (stethoscopes, thermometers, blood pressure cuffs, pulse oximeters) is cleaned and disinfected with an EPA-registered disinfectant after each patient, or left in the home for a patient on contact precautions. Soiled items are bagged and kept apart from clean supplies in vehicles. DME is cleaned between patients by the supplier (Policy CA-HSP-DME-01). Clean supplies at the office are stored off the floor and separate from soiled items (Agency standard).

At admission and as needs change, the registered nurse teaches the patient, family and caregivers how infections spread and how to prevent them: hand hygiene, safe handling of linens and body fluids, cleaning, care of catheters and wounds, safe sharps disposal (home-generated sharps may not go in household trash or recycling containers; Health & Safety Code §118286), and when to call the Agency. Teaching and the family's understanding are recorded (22 CCR §74880(d)(4)(B)(i); 42 CFR §418.60(c)).

• The ATD Plan is written, specific to home-based hospice work, and contains the elements in 8 CCR §5199(d)(2): the person responsible, job classifications with occupational exposure, high hazard procedures if any, tasks requiring personal or respiratory protection, the methods of implementing the standard, and source control measures.
• The ATD Plan is reviewed at least annually by the plan administrator and by employees regarding its effectiveness in their work areas, deficiencies are corrected, and the review is documented in writing (8 CCR §5199(d)(3)).
• Employees with occupational exposure receive ATD training at the time of initial assignment and at least annually, not to exceed 12 months from the previous training, with an opportunity for interactive questions and answers with a knowledgeable person (8 CCR §5199(i)(2), (i)(5); Policy CA-HSP-HR-02). All personnel, contracted providers and volunteers receive infection control education at orientation and at least annually (Agency standard; 22 CCR §74880(d)(4)(B)(i)).
• TB assessments, vaccinations and the medical services 8 CCR §5199(h) requires are in Policy CA-HSP-HR-06.

The program has a method of identifying infectious and communicable disease problems and a plan for actions expected to result in improvement and disease prevention (42 CFR §418.60(b)(2)). The Agency:

• records on Form CA-HSP-IC-01-A every patient infection identified during hospice care (for example, urinary tract infection, pneumonia, skin and wound infection, C. difficile, multidrug-resistant organisms, influenza and COVID-19), staff illnesses that may have been acquired at work or passed to patients, and exposures;
• reviews the log each month to look for clusters and trends by team, setting and organism, and compares them with the previous months;
• audits compliance with hand hygiene, bag technique and PPE by direct observation during supervisory and competency visits, at least ten observations per team each quarter (Agency standard); and
• reports results and actions to QAPI at least quarterly (Policy CA-HSP-QA-01).

Every health care provider, which includes a registered nurse, "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 (17 CCR §2500(b)). The list includes "OUTBREAKS of ANY DISEASE (Including diseases not listed in Section 2500)" and "OCCURRENCE of ANY UNUSUAL DISEASE", which are to be reported immediately by telephone (17 CCR §2500(h), (j)). The urgency of each other listed disease is shown by its symbol in §2500(j): immediately by telephone, within one working day, or within seven calendar days (§2500(h)). Where more than one health care provider may know of a case or outbreak, the person in charge establishes procedures to make sure reports are made (17 CCR §2500(c)). The Agency's procedure:

1. A clinician who suspects an outbreak or an unusual disease calls the DPCS at once. The DPCS, or the clinician if the DPCS cannot be reached, reports immediately by telephone to the local health officer for the patient's county of residence, and records the date, time and person spoken to on Form CA-HSP-IC-01-A.
2. Other reportable diseases diagnosed or suspected in Agency patients are reported within the time frame shown for that disease in 17 CCR §2500(j), using the local health department's Confidential Morbidity Report or electronic system, unless the attending physician confirms that they have already reported it (Agency standard). The DPCS keeps a current copy of the list.
3. The Administrator also notifies CDPH, through the district office that serves the Agency, of every outbreak or undue prevalence of infections, parasitic disease or infestation that the Agency reports to the local health officer (22 CCR §74880(d)(4)(B)(iv)), by the next business day (timing is an Agency standard).
4. Reports contain only the information the rule asks for (17 CCR §2500(d)) and are sent securely (Policy CA-HSP-PRV-01).

When an outbreak or cluster is suspected, the DPCS (22 CCR §74880(d)(4)(B)(v)):

1. confirms the cases and defines who is affected, where and when;
2. puts control measures in place at once, such as added precautions, cohorting staff assignments, restricting ill staff and extra cleaning;
3. follows the instructions of the local health officer and cooperates with any public health investigation;
4. informs affected patients, families and staff, and facilities where affected patients live;
5. records the investigation, the actions and the outcome; and
6. reviews the event in QAPI and updates policies and training (Policy CA-HSP-QA-01).

Sharps containers and other regulated waste generated by Agency staff are handled as Policy CA-HSP-IC-02 and the Medical Waste Management Act (Health & Safety Code §117600 et seq.) require. Patients' and families' home-generated sharps are kept out of trash and recycling containers and are taken in a sharps container to a household hazardous waste facility, a home-generated sharps consolidation point or a medical waste generator's facility, or returned by an approved mail-back container (Health & Safety Code §118286).

Each role named below carries the duties shown.

The Agency keeps the following records and checks compliance as shown.

• Form CA-HSP-IC-01-A surveillance and reporting log, with monthly reviews, kept at least ten years (retention period is an Agency standard).
• The ATD Plan and written annual reviews (8 CCR §5199(d)(3), (j)(3)).
• ATD training records, kept 3 years from the date of training (8 CCR §5199(j)(2)), and employee medical records, kept for the duration of employment plus 30 years (8 CCR §5199(j)(1)(D); Policy CA-HSP-HR-06).
• Reports to the local health officer and CDPH, and outbreak investigation files.
• Monitoring: hand hygiene and bag technique observations, reported quarterly to QAPI.

All personnel, contracted providers and volunteers receive infection control education at orientation and at least annually, covering the science of infectious disease transmission, hand and respiratory hygiene, cough etiquette, PPE, bag technique, cleaning, and how to report infections and suspected outbreaks (22 CCR §74880(d)(4)(B)(i)-(ii)). Employees with occupational exposure also complete the ATD training in 8 CCR §5199(i). Hospice management personnel review the infection control program in their orientation and annual training (22 CCR §74880(d)(4)(B), (e)(1)(B); Policy CA-HSP-HR-01).

This policy implements the following authorities.

• 22 CCR §74880(d)(4)(B), (e)(1)(B), infection control program
• 8 CCR §5199, aerosol transmissible diseases
• 17 CCR §2500, reporting to the local health authority (Cornell LII copy of the California Code of Regulations)
• Health & Safety Code §117600 et seq., Medical Waste Management Act
• Health & Safety Code §118286, home-generated sharps
• 42 CFR §418.60 (Medicare-certified hospices)

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