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, caregivers and staff from infections. "The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases" (42 CFR §484.70), as "an integral part of the HHA's quality assessment and performance improvement (QAPI) program" (§484.70(b)).

This policy covers infection prevention in every patient home and institutional residence, in Agency vehicles and at the office; surveillance of infections in patients and staff; reporting to public health; staff health; and education.

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

The Agency maintains and documents an infection control program whose goal is the prevention and control of infections and communicable diseases (42 CFR §484.70). Staff follow accepted standards of practice, including standard precautions, to prevent the transmission of infections and communicable diseases (§484.70(a)). The program includes a coordinated, agency-wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases, with a method for identifying problems and a plan for actions expected to result in improvement and disease prevention, and is part of QAPI (§484.70(b); Policy MO-HH-QA-01). The Agency provides infection control education to staff, patients and caregivers (§484.70(c)), and reports communicable diseases as 19 CSR 20-20.020 requires.

• The infection prevention lead runs the program, keeps the surveillance log (Form MO-HH-IC-01-A), selects the clinical references the program follows, and reports to the QAPI committee at least each quarter, as the Agency's own standard.
• The infection prevention lead reviews this program at least once a year and whenever national guidance or the Agency's services change, as the Agency's own standard, and the governing body receives the review (Policy MO-HH-GOV-01).
• Supplies needed for infection prevention (alcohol-based hand rub, soap and paper towels, gloves, gowns, masks, respirators, eye protection, disinfectant wipes and sharps containers) are kept stocked at the office and in each clinician's supply bag.

• The supply bag is placed on a clean, dry, hard surface on a barrier, away from pets and children, and never on the floor or bed.
• Hand hygiene is performed before going into the bag. Only the items needed are taken out, and nothing goes back in until it has been cleaned.
• Patients with transmission-based precautions are scheduled last in the day where possible, and only the supplies needed are taken into the home; equipment is left in the home for that patient where practical.
• Clean and dirty items are kept separate in the vehicle. Bags and vehicle storage areas are cleaned at least weekly, as the Agency's own standard, and whenever soiled.

• When a patient is known or suspected to have an infection that needs contact, droplet or airborne precautions, the case manager records it on the plan of care, the aide's written instructions (Policy MO-HH-AID-02) and the schedule, and tells every discipline before the next visit.
• Where the Agency requires staff to wear N95 or other tight-fitting respirators (for example, for suspected or confirmed tuberculosis disease or other airborne infections), it runs a written respiratory protection program under 29 CFR §1910.134. Each such employee receives a medical evaluation before fit testing or first use, is fit tested before initial use, whenever a different respirator facepiece is used and at least annually thereafter, and receives training that recurs annually.
• Patients and caregivers are taught the precautions they should take in the home.

• The method for identifying infectious and communicable disease problems (42 CFR §484.70(b)(1)) is this: clinicians report to the infection prevention lead, within one business day as the Agency's own standard, any infection a patient develops or is treated for while under the Agency's care, and the lead records it on Form MO-HH-IC-01-A.
• Infections tracked include at least urinary tract infections (noting any urinary catheter), surgical site and wound infections, bloodstream infections related to venous access devices, respiratory infections including pneumonia, gastrointestinal infections such as C. difficile, multidrug-resistant organisms, and infections in staff that could spread to patients.
• The lead uses consistent, nationally recognized definitions for each type of infection, so that rates can be compared over time.
• Each month the lead counts infections by type, discipline, device and branch, and calculates rates where enough data exist. Each quarter the results go to the QAPI committee with any trend or cluster.

1. When surveillance shows a cluster, a rise in a rate, an unusual organism, or an infection possibly linked to Agency care, the lead investigates: reviews the records of the patients and staff involved, observes practice, and looks for a common source.
2. The lead writes a plan for the appropriate actions expected to result in improvement and disease prevention (42 CFR §484.70(b)(2)), for example retraining, changes in supplies or procedures, or extra supervision, with a person responsible and a date for each action.
3. The QAPI committee monitors the plan until the problem is resolved, and may make it a performance improvement project (Policy MO-HH-QA-01).
4. An outbreak, or an illness that may be of public health concern, is reported to the local health authority or the Department within the time 19 CSR 20-20.020 sets (Section 11).

19 CSR 20-20.020(6) requires "A physician, physician's assistant, nurse, hospital, clinic, or other private or public institution providing diagnostic testing, screening or care to any person with any disease, condition, or finding listed in sections (1)-(4) of this rule or who is suspected of having any of these diseases, conditions, or findings" to make a case report to the local health authority or the Department, or cause a report to be made by their designee, within the specified time.

• The lists of diseases in each category change from time to time. The infection prevention lead keeps the current list from 19 CSR 20-20.020 and the Department's reportable disease pages, and staff check with the lead or the on-call nurse whenever a patient has or may have a reportable disease.
• A nurse who learns that a patient has, or is suspected of having, a reportable disease tells the infection prevention lead at once. The lead makes the case report as the nurse's designee within the time the rule sets, after checking with the patient's physician whether a report has already been made; duplicate reporting of the same case by providers in the same institution is not required (19 CSR 20-20.020(6)(B)).
• The report includes the information listed in 19 CSR 20-20.020(7), such as the patient's name, home address, date of birth, the disease diagnosed or suspected, date of onset, the attending physician, laboratory results, and the reporter's name and address.
• Disclosures to public health authorities are permitted under HIPAA and are recorded for accounting of disclosures (Policy MO-HH-PRV-01).

• Missouri has no home health rule requiring tuberculosis testing of staff (the Department's tuberculosis testing rule, 19 CSR 20-20.100, applies to long-term care facilities). As the Agency's own standard, following current CDC recommendations for health care personnel, each new employee with patient contact has a baseline tuberculosis screening at hire (a risk assessment, a symptom screen, and a blood test or skin test), and later testing is done after a known exposure or as the program decides; routine annual testing is not required.
• Staff with fever, vomiting or diarrhea, a new rash, conjunctivitis, a draining wound, or symptoms of a respiratory infection tell the clinical manager before visiting and do not visit until cleared. As the Agency's own standard, staff with fever return only when fever-free for at least 24 hours without fever-reducing medicine, and staff with vomiting or diarrhea only after symptoms have stopped for at least 48 hours, unless the clinical manager sets a different return date on medical advice.
• Influenza vaccination is offered to staff each year, as the Agency's own standard. Hepatitis B vaccination is offered as Policy MO-HH-IC-02 requires.
• Staff health information is kept confidential and separate from the personnel file (Policy MO-HH-HR-03).

• Staff receive infection control education at orientation and at least annually, as the Agency's own standard, covering this policy, hand hygiene, personal protective equipment, bag technique, cleaning, transmission-based precautions, device-related infection prevention and reporting (42 CFR §484.70(c); Policy MO-HH-HR-01).
• Patients and caregivers are taught, as their care requires, hand hygiene, care of catheters, wounds and venous access devices, cleaning of equipment at home, safe disposal of sharps (Policy MO-HH-IC-03), signs of infection to report, and vaccinations (42 CFR §484.70(c)). The teaching and the patient's understanding are documented.
• Aide supervision checks that aides comply with infection prevention and control policies and procedures (42 CFR §484.80(h)(4)(iv); Policy MO-HH-AID-02).

Care of urinary catheters, wounds, venous access devices, enteral tubes, tracheostomies and respiratory equipment follows the clinical procedure manual (Policy MO-HH-CS-01), which reflects current national guidance. Aseptic technique is used for every sterile procedure, and the need for each invasive device is reviewed with the practitioner at each plan of care review.

An outbreak of an emerging infectious disease is one of the hazards in the Agency's emergency preparedness program (Policy MO-HH-EP-01). In such an event the infection prevention lead follows guidance from the Department and the local health authority on screening, personal protective equipment, visit prioritization and reporting, and keeps staff informed.

Accountability under this policy is allocated as follows.

The surveillance log (Form MO-HH-IC-01-A), investigation reports, action plans, communicable disease reports, respirator fit test and medical evaluation records, and education records are kept for at least six years, as the Agency's own standard; employee medical records are kept as Policy MO-HH-IC-02 requires. Each quarter the infection prevention lead reports infection rates, trends, actions and the results of hand hygiene and bag technique observations to the QAPI committee.

All staff with patient contact are trained on this policy at orientation and at least annually. Staff who must wear respirators receive respirator training before first use and annually (29 CFR §1910.134). The infection prevention lead keeps current through continuing education in infection prevention.

This policy implements the following authorities.

• 19 CSR 30-26.010(1)(A), Incorporation of 42 CFR Part 484
• 19 CSR 20-20.020, Reporting communicable, environmental and occupational diseases
• 42 CFR §484.70, Infection prevention and control
• 42 CFR §484.65, Quality assessment and performance improvement
• 42 CFR §484.80(h)(4)(iv), Aide compliance with infection prevention and control
• 42 CFR §484.102, Emergency preparedness
• 29 CFR §1910.134, Respiratory protection
• 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 Section 19 is amended, the amendment is recorded in this table and a new version of this policy is issued.