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.

Hospice patients are often frail and their families are tired and close to them. Staff move from home to home and facility to facility. This program protects patients, families, visitors and staff by preventing and controlling infections and communicable diseases (42 CFR §418.60), in a way that fits care given mostly in private homes.

All Agency services in every setting: private homes, adult foster care homes, homes for the aged, assisted living settings, nursing facilities and inpatient units where the Agency arranges care, the Agency office, and staff vehicles and bags.

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

The Agency has an infection prevention and control program and allocates resources to provide: a qualified health care professional designated in writing to be responsible for the program; a designated, multidisciplinary infection control team to collect, analyze and report data; authority and procedures to conduct outbreak investigations; implementation of basic measures for infection prevention; prioritized program needs and initiatives; and ongoing evaluation and revision of the program (R 325.45133(a)-(f)). The Agency follows accepted standards of practice, including standard precautions, maintains a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infectious and communicable diseases that is an integral part of its quality program, and provides infection control education to employees, contracted providers, patients, family members and other caregivers (42 CFR §418.60).

• The governing body designates the infection preventionist in writing on Form MI-HSP-GOV-01-A. The person has completed training in the principles and methods of infection control and keeps the qualification current through ongoing education, shown by one of: certification in infection control (CIC); certification as an ambulatory infection preventionist (CAIP); completion of an infection control course; or participation in meetings that include infection control organized by recognized professional societies or other associations applicable to the Agency's services (R 325.45133(a)). Evidence is kept in the person's personnel file.
• The infection control team is the infection preventionist, the director of nursing, the medical director or a hospice physician, Lee Sample (Quality program lead) for the quality program, and at least one nurse and one hospice aide who give direct care (Agency standard). The team meets at least quarterly and whenever an outbreak is suspected (Agency standard).
• The infection preventionist has authority to start an outbreak investigation at any time, to require staff to follow control measures, and to restrict a staff member from patient care when the restriction criteria in Policy MI-HSP-HR-05 are met (R 325.45133(c); R 325.45139(1)(c)).
• The Administrator provides the supplies, PPE, hand hygiene products, disinfectants, training time and data systems the program needs.
• Each year the team sets the program's priorities from the surveillance data, the risks of the patients the Agency serves and community disease activity, and evaluates and revises the program (R 325.45133(e)-(f)).

• Staff clean their hands before and after every patient contact, before clean or aseptic tasks, after contact with body fluids or contaminated surfaces, after removing gloves, and before leaving the home.
• Alcohol-based hand rub is used unless hands are visibly soiled, in which case staff wash with soap and water. Staff carry hand rub, liquid soap and paper towels in every visit bag.
• Outside a hospice patient's private residence, single-use disposable hand towels are used for hand hygiene and common-use hand towels are prohibited (R 325.45135(4)(e)). In a private residence that rule does not apply, but staff still dry their hands with their own paper towels and do not use household towels (Agency standard).
• Staff who give hands-on care keep nails short and do not wear artificial nails (Agency standard).
• The infection preventionist or a supervising nurse observes and records hand hygiene during supervisory and other visits (R 325.45137(d)(i)).

• Gloves are worn for contact with blood, body fluids, mucous membranes, broken skin or contaminated items; gowns, masks and eye protection are added when splashes or sprays are possible.
• The Agency provides PPE in the sizes staff need at no cost to staff. PPE is put on before entering the care area when transmission-based precautions apply and removed before leaving the home, followed by hand hygiene.
• Bloodborne pathogen requirements for PPE are in Policy MI-HSP-IC-02.

• Staff with respiratory symptoms do not make visits until cleared under Policy MI-HSP-HR-05; persons with signs of infection who have direct physical contact with patients participate only when free of signs of infection (R 325.45145(2)).
• Patients and family members with a cough are offered a mask, tissues and hand rub during visits, and taught to cover coughs and sneezes.

• One needle, one syringe, one time: needles and syringes are single use.
• Single-dose vials are used for one patient only; multi-dose vials, if used, are dated when opened and kept for one patient in the home.
• Infusion and subcutaneous lines are set up with aseptic technique and labeled with the date.
• Used sharps go straight into a puncture-resistant sharps container (Policy MI-HSP-IC-02).
• Safe injection practice is monitored through record review and observation (R 325.45137(d)(v)).

The rules require safe handling of potentially contaminated equipment or surfaces in the patient environment, which for a hospice includes a private residence (R 325.45135(2)(e)).

• Bag technique: the visit bag is placed on a clean, dry surface or a barrier; hands are cleaned before reaching into the bag; only the items needed are taken out; used items never go back into the clean part of the bag.
• Reusable items that touch intact skin, such as stethoscopes, blood pressure cuffs, thermometers and pulse oximeters, are cleaned and disinfected after each patient with an EPA-registered disinfectant used as its label directs, including contact time (R 325.45137(d)(vi)). Where possible, items stay in the home for that patient's use.
• Items that cannot be cleaned are single use. Staff do not carry patient supplies from one home to another.
• Medical equipment supplied for the patient is cleaned and maintained by the supplier as Policy MI-HSP-DME-01 sets; staff report damaged or soiled equipment.

The written procedures cover contact, droplet, airborne and multi-route precautions (R 325.45135(3)). When a patient has, or is suspected of having, an infection that needs them, the RN case manager records the precautions in the plan of care and tells everyone who visits.

The infection preventionist keeps the precaution guide current with CDC guidance and tells staff of any change.

The written procedures cover cleaning and disinfecting environmental surfaces, floors and furniture; cleaning and disinfecting objects shared by patients, staff and visitors; disposal of regulated and non-regulated medical and non-medical waste; and screening for and management of patients infested with ectoparasites (R 325.45135(4)).

• Agency office and vehicles: surfaces and shared objects are cleaned on a schedule the infection preventionist sets; visit bags are cleaned weekly and when soiled (Agency standard).
• Patients' homes: staff teach families how to clean surfaces, launder soiled linens separately in hot water, and keep the patient's area clean. Aides clean the areas of the home the patient uses as their care instructions allow (Policy MI-HSP-AIDE-01).
• Waste: staff place used dressings and similar waste in a sealed bag in the household trash; sharps and regulated waste are handled under Policy MI-HSP-IC-02. Families are taught to put household sharps in a puncture-resistant container with a secure lid.
• Ectoparasites: at admission and each visit staff look for signs of scabies, lice or bed bugs. If found, the nurse tells the physician for treatment orders, uses contact precautions, keeps the visit bag outside or in a sealed bag, and teaches the family how to treat linens and the home. Staff check their own clothing after the visit.

The Agency keeps an active surveillance program for infection detection through ongoing data collection and analysis that includes patients and personnel who have access to or contact with patient care areas (R 325.45137(a)).

• Nurses record on the visit note any sign of a new infection, the site, any culture or test result and the treatment ordered. The infection preventionist enters each case on Form MI-HSP-IC-01-A.
• Staff illnesses that may be infectious are reported to the infection preventionist and entered on the log without the staff member's name in shared reports (Policy MI-HSP-HR-05).
• The infection preventionist uses consistent written case definitions (Agency standard) and analyzes the data monthly: number of infections by type, rate per 1,000 patient days, organisms, device-associated infections and clusters.
• An ongoing program prevents, controls and investigates healthcare-associated infections (R 325.45137(c)).

The program monitors the items in R 325.45137(d) that apply to hospice care:

The Agency reports communicable diseases in compliance with MCL 333.5111 and the communicable and related diseases rules, R 325.171 to R 325.199 (R 325.45137(b)).

• A physician must report each case of a serious communicable disease on the state list, and the unusual occurrence of any disease, infection or condition that threatens the health of the public, within 24 hours of diagnosis or discovery to the appropriate local health department (R 325.173(1)-(2)).
• When a hospice physician or nurse practitioner diagnoses or discovers a reportable disease, the infection preventionist makes sure the report is made within that time, and confirms with the attending physician that the attending physician has reported when the attending physician made the diagnosis.
• An administrator, infection control professional or nurse may also report to the appropriate local health department any designated condition or other disease that poses a threat to the health of the public (R 325.173(8)). The infection preventionist reports suspected outbreaks among patients or staff to the local health department the same day they are identified (Agency standard).
• Reports go to the local health department for the county where the patient lives, by the method that department prescribes (R 325.173(10)). The infection preventionist keeps current local health department contacts for every county the Agency serves (Ingham and Eaton Counties).
• Reports are recorded on Form MI-HSP-IC-01-A with the date, time, person reporting and the health department contact.

1. Any staff member who notices two or more patients or staff with similar infections close in time tells the infection preventionist the same day.
2. The infection preventionist confirms the cases, writes a case definition, lists the cases on Form MI-HSP-IC-01-A and looks for common staff, settings or equipment.
3. The infection preventionist starts control measures at once (precautions, staff assignment changes, extra cleaning, work restrictions under Policy MI-HSP-HR-05) and notifies the local health department, the director of nursing, the medical director and the Administrator.
4. The team follows the health department's directions, tells affected facilities and families, and keeps a written record of actions and dates.
5. When the outbreak ends, the team writes a summary of causes, actions and lessons and reports it to the quality program.

• All personnel, including employees, onsite contract workers, medical providers, students and volunteers, receive education and training on methods to prevent or reduce the transmission of infectious agents upon hire and at ongoing intervals (R 325.45141(1)). The Agency's interval is at least once a year and whenever procedures change (Agency standard; Policy MI-HSP-HR-01).
• Compliance with initial and ongoing training is documented (R 325.45141(2)).
• Patients, families and visitors are given information on methods to prevent or reduce the transmission of infectious agents (R 325.45141(3); 42 CFR §418.60(c)): hand hygiene, cough etiquette, care of devices, safe handling of linens and waste, and when to call the nurse. Teaching is recorded in the clinical record.

The Agency documents how infection prevention and control is integrated into its quality assessment and performance improvement program, including actions taken in response to data analysis to improve infection control performance and patient outcomes, and the measures selected for monitoring, data collection, analytical methods, actions taken and outcomes (R 325.45143(1)). Infection prevention and quality activities are continuous and based on surveillance results (R 325.45143(2)). The infection preventionist reports the quarterly surveillance summary to the quality program, which includes infection measures in its program (42 CFR §418.58; Policy MI-HSP-QA-01).

Accountability under this policy is allocated as follows.

The infection preventionist keeps Form MI-HSP-IC-01-A, monthly analyses, team minutes, outbreak summaries, communicable disease reports, hand hygiene observations and training records. Patient infections, precautions and teaching are recorded in the clinical record (Policy MI-HSP-REC-01). Employee files hold baseline screening for communicable diseases or immunizations and records of illness and accidents occurring on duty (R 325.45145(1); Policy MI-HSP-HR-04). Program records are administrative records kept under the Agency's retention schedule (seven years).

Training on this policy is part of orientation for every staff member and volunteer before patient contact, and is repeated at least once a year (R 325.45141). Nurses and aides also complete a hand hygiene, PPE and bag technique competency at hire and each year (Policy MI-HSP-HR-01).

This policy implements the following authorities.

• Mich. Admin. Code R 325.45133, infection prevention and control program
• Mich. Admin. Code R 325.45135, infection prevention and control policies and procedures
• Mich. Admin. Code R 325.45137, surveillance, prevention and communicable disease reporting
• Mich. Admin. Code R 325.45139, personnel screening, immunization and mitigation
• Mich. Admin. Code R 325.45141, education and training
• Mich. Admin. Code R 325.45143, integration with quality assurance and performance improvement
• Mich. Admin. Code R 325.45145, employee health and communicable disease
• MCL 333.5111, reportable diseases
• Mich. Admin. Code R 325.171 to R 325.199, communicable and related diseases, including R 325.173 reporting
• 42 CFR §418.58, quality assessment and performance improvement
• 42 CFR §418.60, infection control

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.