Infection Prevention and Control Program

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 sets up an effective infection control program designed to reduce the transmission of infections in patients, health care workers, caregivers, families, visitors and volunteers.

This policy covers infection prevention and control in all components of the hospice: home care in private homes and facilities, and any residential or inpatient hospice care facility.

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

The Agency has an effective infection control program designed to reduce the transmission of infections in patients, health care workers, caregivers, families, visitors and volunteers (Ga. Comp. R. & Regs. 111-8-37-.12). The Agency has an infection control surveillance plan tailored to its needs and its patients that includes both outcome and process surveillance (Rule 111-8-37-.12(a)). Its infection control policies and procedures address all components of the hospice, are based on accepted standards of infection control, are approved by the Administrator and the medical director, and address at least the 16 subjects in Table 1 (Rule 111-8-37-.12(b)). The program is evaluated at least annually (Rule 111-8-37-.12(c)). If the Agency is Medicare-certified, the program also follows accepted standards of practice including standard precautions, is an integral part of the quality assessment and performance improvement program, and includes infection control education for employees, contracted providers, patients, family members and other caregivers (42 CFR §418.60). Table 1 shows where each subject that Rule 111-8-37-.12(b) lists is covered.

• The infection control lead coordinates surveillance, audits, education and outbreak response, and reports to the quality management committee at least quarterly (Rule 111-8-37-.09(2)(f)).
• The medical director advises on clinical infection questions, antibiotic use and outbreak response, and approves the infection control policies with the Administrator (Rule 111-8-37-.12(b)).
• The Administrator makes sure supplies (hand sanitizer, PPE, disinfectants, sharps containers, specimen supplies) are always available to staff at no cost.

• Staff clean their hands with alcohol-based hand rub or soap and water: on arrival and before leaving the home, before and after touching the patient, before a clean or aseptic task, after contact with body fluids, after removing gloves, and after touching the patient’s surroundings.
• Soap and water is used when hands are visibly soiled and after caring for a patient with diarrhea or known or suspected Clostridioides difficile or norovirus.
• Fingernails are kept short; artificial nails are not worn by staff giving hands-on care.

• Standard precautions are used with every patient (42 CFR §418.60(a)).
• Gloves, gowns, masks, eye protection and respirators are chosen for the task and the patient’s known or suspected infection, put on and removed in the correct order, and disposed of in the home before leaving.
• Transmission-based precautions (contact, droplet or airborne) are added on an order or when the nurse suspects an infection that requires them, following current CDC isolation guidance. In the home, the nurse teaches the family how to protect themselves and others, and staff who visit wear the required PPE. Fit-tested respirators are used for airborne precautions.
• Exposure to blood or other potentially infectious materials is reported and followed up under Policy GA-HSP-IC-02.

Nurses follow the Agency’s procedure manual, based on current CDC and professional guidance, for:

• Wound care: clean technique for chronic wounds unless the order requires sterile technique; single-patient supplies; safe disposal of dressings.
• Urinary tract care: insert catheters only on order and with aseptic technique; keep closed drainage and the bag below the bladder; daily perineal hygiene; change catheters on symptoms or as ordered, not on a fixed schedule unless ordered.
• Respiratory therapy: clean and dry oxygen and nebulizer equipment as the manufacturer instructs; use sterile or distilled water where required; replace tubing and masks at the supplier’s interval; aseptic suctioning technique.
• Enteral therapy: hand hygiene before handling; clean preparation; flushing and site care as ordered; correct hang times for feeds.
• Infusion therapy: aseptic technique for access and dressing changes; scrub the hub before every access; date dressings; assess the site at every visit; remove lines no longer needed.

• Reusable equipment carried between homes (stethoscopes, blood pressure cuffs, thermometers, pulse oximeters) is cleaned and disinfected with an EPA-registered disinfectant, following the product’s contact time, after each patient. Single-patient items stay in the home.
• Nursing bags are kept off the floor on a clean barrier; staff take out what they need after hand hygiene and do not return used items to the bag.
• The Agency does not sterilize instruments; sterile items are bought sterile and single use. DME is cleaned between patients by the supplier (Policy GA-HSP-DME-01).

• Sharps used by staff go into a puncture-resistant sharps container immediately after use. Full containers are closed and disposed of through the Agency’s licensed medical waste service or as local rules allow.
• Families who use sharps at home are taught to use a sturdy closed container and to dispose of it as the local solid waste authority advises.
• Dressings and other items soaked with blood are bagged and disposed of in line with Georgia environmental rules and local requirements, and with Policy GA-HSP-IC-02.
• Laboratory specimens are collected, labeled, packaged and transported as Policy GA-HSP-LAB-01 requires.

Georgia Environmental Protection Division rules on biomedical waste were not read for this policy; the Administrator confirms the Agency’s waste handling with its waste contractor and the local authority.

At admission and when circumstances change, the RN assesses and records infection risks (Rule 111-8-37-.12(b)13.): the patient’s devices, wounds and immune status; known infections or colonization; access to running water and hand-washing supplies; cleanliness; pets and pests; others in the home who are ill; and the caregiver’s ability to follow precautions. The plan of care includes the infection prevention measures and teaching that follow from the assessment.

The surveillance plan includes both outcome and process surveillance (Rule 111-8-37-.12(a)) and is a part of the quality program (42 CFR §418.60(b)(1)).

• Outcome surveillance: nurses record each new infection on Form GA-HSP-IC-01-A at the time it is found, using simple written definitions the infection control lead keeps with the form (for example, a new urinary tract infection treated with an antibiotic). Staff infections reported under Policy GA-HSP-HR-05 are tracked separately and confidentially.
• Process surveillance: each quarter the infection control lead audits a sample of visits or records for hand hygiene, bag technique, catheter care and equipment cleaning, and reviews sharps injuries and exposures (Agency standard).
• The infection control lead calculates infection rates per 1,000 patient days, looks for clusters by organism, team or setting, and reports to the quality management committee quarterly with a plan for any problem found (42 CFR §418.60(b)(2)).

1. A possible outbreak is two or more patients or staff with the same infection linked by time, place or caregiver, or any single case of a disease the DPH roster lists as immediately reportable (Agency definition).
2. The staff member who suspects an outbreak tells the infection control lead the same day. The lead tells the Administrator and the medical director, confirms the cases, and starts a line list.
3. The lead puts control measures in place (for example, extra precautions, cohorting of staff, restricting sick staff under Policy GA-HSP-HR-05, extra cleaning), contacts the county health department or the Department of Public Health for advice, and reports as Section 10 requires.
4. When the outbreak is over, the lead writes a short report of what happened and what changed, for the quality management committee.

• Georgia law requires reporting of notifiable diseases to the Department of Public Health (O.C.G.A. §31-12-2; Ga. Comp. R. & Regs. 511-2-1-.02). The Agency reports as Rule 111-8-37-.12(b)16. requires.
• When a nurse learns that a patient has a notifiable disease, the nurse checks whether the diagnosing physician or laboratory has reported it. If not, or if in doubt, the infection control lead reports it within the time the DPH notifiable disease roster sets for that disease (immediately for some, within days for others).
• Contact: Georgia Department of Public Health: 1-866-782-4584 (1-866-PUB-HLTH) for conditions that must be reported immediately; other conditions through SendSS. The county health department can also take reports.
• The report and the date and time it was made are recorded on Form GA-HSP-IC-01-A.

The infection control lead keeps the current DPH roster with this policy and checks the DPH website for updates at least yearly.

• Staff and volunteers receive infection control education at orientation and every year, including emerging trends in infection control (Rule 111-8-37-.13(4)(a)).
• Contracted providers receive the Agency’s infection control requirements in their orientation and contract (42 CFR §418.60(c)).
• Patients, families and other caregivers are taught hand hygiene, safe care of devices and wounds, disposal of sharps and soiled items, signs of infection to report, and any isolation measures, and the teaching is recorded (42 CFR §418.60(c)).

At least annually, the infection control lead, the Administrator and the medical director evaluate the effectiveness of the program related to the prevention of the transmission of infections to patients, health care workers, caregivers, families, visitors and volunteers (Rule 111-8-37-.12(c)). The evaluation reviews the year’s surveillance data, audits, exposures, outbreaks, education completed and changes in guidance, and sets goals for the next year. It is presented to the quality management committee and the governing body, and this policy is revised if needed.

Each role named below carries the duties shown.

The following are kept.

• The signed approval of the infection control policies by the Administrator and the medical director.
• Form GA-HSP-IC-01-A and quarterly surveillance reports.
• Process audit results and outbreak reports.
• Records of notifiable disease reports.
• The annual program evaluation and the governing body’s review.
• Education records for staff and volunteers (Policy GA-HSP-HR-01).

All staff and volunteers receive infection control training at orientation and annually, covering hand hygiene, standard and transmission-based precautions, PPE, bag technique, cleaning of equipment, sharps safety, recognizing and reporting infections and emerging trends in infection control (Rule 111-8-37-.13(4)(a)). Nurses are also trained in the clinical procedures in Section 6.3.

This policy implements the following authorities.

• Ga. Comp. R. & Regs. 111-8-37-.12, Infection Control
• Ga. Comp. R. & Regs. 111-8-37-.09(2)(f), quality review of infection control
• Ga. Comp. R. & Regs. 111-8-37-.13(4)(a), (5), annual training and health screening
• Ga. Comp. R. & Regs. 111-8-37-.24(2)(j)-(k), infection control in hospice care facilities
• O.C.G.A. §31-12-2, reporting of diseases
• Ga. Comp. R. & Regs. 511-2-1-.02, notifiable disease reporting
• Georgia Department of Public Health, Notifiable Disease Reporting Requirements (roster)
• 42 CFR §418.60, Infection control (Medicare-certified hospices)
• 29 CFR §1910.1030, Bloodborne pathogens

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.