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 protects patients, families, visitors and staff by preventing and controlling infections and communicable diseases, and makes sure the Agency reports reportable diseases to public health as Louisiana law requires.

This policy covers all care in patients’ homes, residential facilities and, if the Agency holds an inpatient facility sublicense, its inpatient facility, as well as the Agency’s office and equipment.

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

The Agency maintains and documents 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). It follows accepted standards of practice, including standard precautions (§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 program (§418.60(b)); and provides infection control education to employees, contracted providers, patients, and family members and other caregivers (§418.60(c)). Its nurses, social workers and other health care professionals report reportable diseases and conditions to the Office of Public Health as LAC 51:II.105 requires.

1. The director of nurses, who supervises the employee health program and promotes the health and safety of employees, patients and the community (LAC 48:I §8217.E.2.d-e), is responsible for the program and designates the infection control lead in writing (Agency standard).
2. The infection control lead keeps the program current with CDC and Louisiana Office of Public Health guidance, reviews the patient infection log monthly, advises staff, and reports to the quality program at least quarterly (Agency standard; Policy LA-HSP-QA-01).
3. The program and this policy are reviewed at least once a year and whenever new public health guidance requires (Agency standard).

1. Hand hygiene: staff clean their hands with alcohol-based hand rub or soap and water on arrival and before leaving, before and after patient contact, before clean or aseptic tasks, after contact with body fluids, and after removing gloves. Soap and water are used when hands are visibly soiled and after caring for a patient with diarrhea that may be infectious (Agency standard, based on CDC guidance).
2. Personal protective equipment (gloves, gowns, masks, eye protection) is supplied by the Agency and worn whenever contact with blood, body fluids, mucous membranes or non-intact skin is expected, and for transmission-based precautions (Policy LA-HSP-IC-02).
3. Bag technique: the nursing bag is placed on a clean, dry surface or a barrier, opened only after hand hygiene, and items that enter the bag are clean; equipment used on the patient is cleaned before it goes back in the bag (Agency standard).
4. Reusable equipment (stethoscopes, blood pressure cuffs, thermometers, pulse oximeters, scales) is cleaned and disinfected with an EPA-registered disinfectant, following the product’s contact time, after each patient. Where possible, equipment is left in the home of a patient on transmission-based precautions for that patient’s use only (Agency standard).
5. Safe injection practices: one needle and one syringe, one time; single-dose vials for one patient only (Agency standard, based on CDC guidance).
6. Respiratory hygiene: staff with respiratory symptoms follow the work restrictions in Policy LA-HSP-HR-05; masks are offered to coughing patients and family when staff are present.
7. Urinary catheters, wounds, ostomies, feeding tubes and suction are cared for with aseptic or clean technique as the procedure requires. Aides never perform sterile or invasive procedures (LAC 48:I §8217.G.3.a).

1. When a patient is known or suspected to have an infection that needs contact, droplet or airborne precautions (for example scabies, Clostridioides difficile, multidrug-resistant organisms in draining wounds, influenza, COVID-19, tuberculosis), the registered nurse case manager adds the precautions to the plan of care and tells every discipline and volunteer before their next visit (Agency standard).
2. Precautions are no more restrictive than needed and preserve the patient’s dignity and family contact; the visit schedule is arranged so that staff see such patients last in the day where practical (Agency standard).
3. Staff who will see a patient on airborne precautions wear a fit-tested respirator and are included in the Agency’s respiratory protection arrangements (Agency standard; Policy LA-HSP-HR-05).

The registered nurse teaches the patient, family members and other caregivers, at admission and when needs change, about hand hygiene, safe handling of soiled linen and waste, cleaning of surfaces and equipment, care of catheters and wounds, signs of infection to report, and any precautions in the plan of care. Teaching is documented in the clinical record (42 CFR §418.60(c)).

1. Each clinician who identifies a new infection in a patient (for example urinary tract, respiratory, skin or wound, bloodstream, gastrointestinal, eye) reports it to the infection control lead and records it on Form LA-HSP-IC-01-A, with the date of onset, signs, any culture, treatment ordered and whether the infection may be related to care (Agency standard).
2. The infection control lead uses the same written definitions for each infection type each month so that data can be compared over time (Agency standard), and also tracks staff infections and exposures reported under Policies LA-HSP-HR-05 and LA-HSP-IC-02.
3. Each month the infection control lead reviews the log for clusters, unusual organisms, infections linked to a device or procedure, and trends by team or setting, and decides on actions such as re-training, audits or changes in practice (42 CFR §418.60(b)(2)).
4. Hand hygiene, bag technique and equipment cleaning are audited at supervisory visits and in a sample of home visits each quarter (Agency standard).

The infection control program is an integral part of the Agency’s quality assessment and performance improvement program (42 CFR §418.60(b)(1)). Infection data, audit results, outbreaks and actions taken are reported to the quality program at least quarterly, and improvement actions are measured to see whether they worked (Policy LA-HSP-QA-01).

1. Under the Louisiana Sanitary Code it is the duty of every nurse, nurse practitioner, physician assistant, social worker, infection control practitioner 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). Physicians have the same duty (§105.A).
2. Reports are made within the time set for the class of the disease or condition (LAC 51:II.105.D, as amended October 2025): Class A within 24 hours, by telephone or another electronic format acceptable to the Office of Public Health, immediately upon recognition, and this also covers all cases of rare or exotic communicable diseases, unexplained deaths, unusual clusters of disease and all outbreaks; Class B within one business day; Class C and Class D within five business days; and Class E (occupational diseases or conditions) within 10 business days.
3. The list of diseases in each class is set by the state health officer and changes from time to time (LAC 51:II.103). The infection control lead keeps the current list from the Louisiana Department of Health with this policy and checks it each year.
4. Reports go to the Office of Public Health: 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 Agency does not wait for a laboratory or another provider to report: to avoid duplicate reports, the nurse first checks with the infection control lead, who confirms whether the attending physician or laboratory has already reported, but the report is made within the time limit in any case (Agency standard).
5. Each report is recorded on Form LA-HSP-IC-01-A with the date, time, person contacted and method.
6. When a patient with a known or diagnosed virulent contagious disease dies, the coroner is notified of the disease (R.S. 13:5712(C); Policy LA-HSP-DTH-01).

1. If the infection control lead suspects an outbreak among patients or staff, he or she tells the director of nurses and the Administrator the same day and reports it to the Office of Public Health as a Class A event within 24 hours (LAC 51:II.105.D.1).
2. The Agency follows the Office of Public Health’s instructions on control measures, testing, staff exclusion and notification of patients and families.
3. During a declared public health emergency, the emergency preparedness plan applies (Policy LA-HSP-EP-01), and, if the Agency holds an inpatient facility sublicense, the visitation rules in Policy LA-HSP-FAC-04.

1. Hospice inpatient facilities and any facility that provides hospice services are maintained in a manner which provides for maintaining personal hygiene of the patients and implementation of infection control procedures (LAC 48:I §8247.H). In a nursing facility or other residential setting, Agency staff follow this policy and the facility’s infection control rules, and report infections to the facility as the written agreement provides (Policy LA-HSP-FAC-01).
2. If the Agency holds an inpatient facility sublicense, the facility also makes provisions for isolating patients with infectious diseases, including the elements listed in §8247.L.7.a-n, should institute the most current CDC recommendations for the specific infection, handles linens to prevent the spread of infection (§8247.L.6), and isolates infected patients only to the degree needed to isolate the infecting organism, by the least restrictive method that maintains the integrity of the process and the dignity of the patient (§8247.L.8). The tuberculosis testing rules of LAC 51:II.503 apply to inpatient facility staff (Policy LA-HSP-HR-05). Policy LA-HSP-FAC-03 sets out the facility procedures.

1. Every employee, contracted provider and volunteer receives infection control education at orientation and every year (42 CFR §418.60(c)). Volunteers’ training includes infection control (LAC 48:I §8217.Q.3.k; Policy LA-HSP-VOL-01).
2. Hospice aides are evaluated on basic infection control procedures in the competency evaluation, and compliance with infection control policies is assessed at supervisory visits (42 CFR §418.76(b)(3)(iv), (h)(3)(iv); Policy LA-HSP-AIDE-01).
3. Contracted providers confirm in their agreements that their staff are trained in infection control and follow this policy in the Agency’s patients’ homes (Policy LA-HSP-CON-01).

Each role named below carries the duties shown.

Form LA-HSP-IC-01-A, monthly reviews, audit results, reportable disease reports, outbreak records and education records are kept by the infection control lead for at least six years (Agency standard). Infection details for a patient are also recorded in the clinical record. Quarterly summaries are part of the quality program records (Policy LA-HSP-QA-01).

See Section 14. Training content includes hand hygiene, personal protective equipment, bag technique, equipment cleaning, transmission-based precautions, recognizing infections, the patient infection log and how to report a reportable disease.

This policy implements the following authorities.

• 42 CFR §418.60, Infection control
• 42 CFR §418.58, Quality assessment and performance improvement
• 42 CFR §418.76(b)(3)(iv) and (h)(3)(iv), Aide infection control competency and supervision
• LAC 48:I §8217.E.2.d-e, Director of nurses: employee health and safety
• LAC 48:I §8217.Q.3.k, Volunteer training in infection control
• LAC 48:I §8247.H and L.6-8, Inpatient facility infection control and isolation
• LAC 51:II.101, 103 and 105, Sanitary Code disease reporting (§105 last amended LR 51:1616, October 2025)
• LAC 51:II.503, Tuberculosis testing (inpatient facility)
• R.S. 13:5712(C), Coroner notification of virulent contagious disease

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.