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, finding and investigating them early, and making sure everyone who gives care knows and follows accepted infection control practice.

This policy covers the infection control program, standard and transmission-based precautions, care in the home and in facilities, surveillance and investigation, communicable disease reporting, education and compliance monitoring.

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

The Agency identifies the person or persons responsible for implementing, maintaining and documenting an infection control program for surveillance, identification, prevention, control and investigation of infections and communicable diseases (19 CSR 30-35.010(1)(I)1). The program includes a system for periodic review and update of infection control policies and procedures; infection control education of staff, patients and caregivers; and monitoring for compliance with policies and procedures (19 CSR 30-35.010(1)(I)2). Infection control policies and procedures conform with accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases (19 CSR 30-35.010(1)(I)3). If the Agency is Medicare-certified, it maintains and documents an effective infection control program that is an integral part of its quality assessment and performance improvement program, and provides infection control education to employees, contracted providers, patients, and family members and other caregivers (42 CFR §418.60).

The infection control lead is the person designated on Form MO-HSP-GOV-01-A as responsible for the infection control program (the infection control lead). The lead:

• Keeps this policy and the infection control procedures current with CDC guidance and reviews them at least once a year and whenever CDC or the Department changes its guidance (Agency standard).
• Keeps the surveillance log (Form MO-HSP-IC-01-A), reviews it each month, investigates clusters, and reports the results to QAPI each quarter (Policy MO-HSP-QA-01).
• Plans infection control training for staff and the teaching materials for patients and caregivers.
• Runs the compliance monitoring in Section 11.
• Advises staff on precautions for individual patients and on exposures, and makes or confirms communicable disease reports (Section 10).
• Works with the disaster coordinator, Avery Sample, on the infectious disease part of the emergency plan (Policy MO-HSP-EP-01).

Every staff member and volunteer uses standard precautions with every patient (19 CSR 30-35.010(1)(I)3):

• Carry only the supplies needed into the home. Leave other supplies in a clean container in the vehicle trunk, away from used items.
• Place the bag on a clean, dry surface, on a barrier (paper towel or pad), away from children and pets. Never place it on the floor or the patient's bed.
• Clean hands before opening the bag. Take out what is needed before care starts. If something else is needed during care, remove gloves and clean hands before going back into the bag.
• Clean and disinfect reusable equipment before putting it back in the bag.
• For a patient on contact precautions, leave dedicated equipment in the home where possible, or take in only disposable items and the minimum equipment, and visit that patient last in the day where the schedule allows.
• Clean the bag inside and out at least once a week and whenever it is soiled (Agency standard).

When a patient is known or suspected to have an infection spread by contact, droplets or the air, the case manager RN tells all staff who visit, adds the precautions to the plan of care and to the aide instructions, and teaches the family. Staff follow current CDC guidance for the infection.

Staff use a respirator only after medical evaluation, fit testing and training under the Agency's respiratory protection procedures. Patients are never refused hospice care because of an infection.

• Staff record on Form MO-HSP-IC-01-A every patient infection that is diagnosed or treated while the patient is in the Agency's care, including urinary tract infections, pneumonia, skin and wound infections, infections related to catheters or lines, multidrug-resistant organisms, influenza, COVID-19 and other communicable diseases, and every staff infection or exposure reported under Policy MO-HSP-HR-05 or Policy MO-HSP-IC-02.
• The case manager RN completes the entry within two business days of learning of the infection (Agency standard).
• The infection control lead reviews the log each month for trends, looks at infection rates by type and by team, and asks whether any infection may have been linked to care (for example, a catheter-related infection).
• Two or more patients or staff with the same infection linked in time or place, or any single case of an unusual or reportable disease, is investigated at once: the lead reviews the cases, talks with the staff involved, looks at practice, and puts control measures in place.
• Results and actions are reported to QAPI each quarter, and the program is part of the QAPI plan (Policy MO-HSP-QA-01).

Missouri requires a physician, physician's assistant, nurse, hospital, clinic or other institution providing care to a person with a reportable disease, condition or finding, or suspected of having one, to make a case report to the local health authority or the Department, or cause a report to be made by a designee, within the time the rule sets for that disease (19 CSR 20-20.020(6)). The rule groups diseases into those reportable immediately by telephone, within one calendar day, within three calendar days, weekly and quarterly (19 CSR 20-20.020(1)-(5)).

• A staff member who learns that a patient has, or is suspected of having, a disease on the Department's reportable disease list tells the infection control lead the same day.
• The infection control lead checks the current list and time frame and finds out whether the diagnosing physician, hospital or laboratory has already reported. If not, the lead makes the report, or makes sure it is made, within the time frame, and records the date, time, method and the person reported to.
• Immediately reportable diseases are reported by telephone to the local health authority or to the Department at 1-800-392-0272 (19 CSR 20-20.020(1)).
• The report includes the information the rule lists for a case report (19 CSR 20-20.020(7)) and is shared only as HIPAA permits for public health reporting (Policy MO-HSP-PRV-01).
• The Agency follows the local health authority's instructions on control measures.

The infection control program includes monitoring for compliance with policies and procedures (19 CSR 30-35.010(1)(I)2). The Agency monitors as follows (Agency standard):

• During RN aide supervisory visits and LPN supervisory visits, the RN observes and records hand hygiene, PPE use and bag technique (Forms MO-HSP-AIDE-01-B and MO-HSP-NUR-01-A).
• Each quarter, the infection control lead or a delegate observes at least five visits by different staff, using a checklist of the practices in Sections 6 and 7.
• Each quarter, the lead checks a sample of clinical records for infection control teaching of patients and caregivers and for precautions in the plan of care where needed.
• Results below 90 percent compliance on any item lead to retraining and a repeat check within 30 days, and are reported to QAPI.

• Patient care employees are oriented to universal precautions before their first visit (19 CSR 30-35.010(2)(M)1.B(VI)), and patient care volunteers are oriented to universal precautions (19 CSR 30-35.010(2)(J)5.H). All staff receive infection control training at orientation and every year, including hand hygiene, PPE, bag technique, transmission-based precautions and this policy (Agency standard).
• At admission and when a new risk arises, the nurse teaches the patient and caregivers hand hygiene, safe handling of soiled linen and waste, care of catheters, wounds or lines in the home, signs of infection to report, and how to protect other household members. The teaching is documented in the clinical record.
• Contracted providers receive the Agency's infection control procedures and confirm in writing that their staff follow them (Policy MO-HSP-CON-01).

Supplies are stored and maintained in a clean and proper manner (19 CSR 30-35.010(2)(I)5). The Agency has policies and procedures for cleaning, storing, accessing and distributing hospice-owned equipment (19 CSR 30-35.010(2)(I)4; Policy MO-HSP-DME-01). Clean and used items are kept apart in the office and in vehicles.

Each role named below carries the duties shown.

The following records are kept:

• Form MO-HSP-GOV-01-A naming the infection control lead.
• Form MO-HSP-IC-01-A and the monthly and quarterly reviews.
• Communicable disease reports made or confirmed.
• Compliance observations and record checks, with the action taken.
• Training records for staff and the dates infection control policies were reviewed and updated.

As in Section 12. The infection control lead completes training in infection prevention for home-based or hospice care and keeps up to date with CDC guidance (Agency standard).

This policy implements the following authorities.

• 19 CSR 30-35.010(1)(I)1-3, infection control
• 19 CSR 30-35.010(1)(E)2.D, accepted standards of practice
• 19 CSR 30-35.010(2)(I)4-5, equipment and supplies
• 19 CSR 30-35.010(2)(J)5.H and (2)(M)1.B(VI), universal precautions orientation
• 19 CSR 30-35.010(2)(N), quality assessment and performance improvement
• 19 CSR 20-20.020, reporting infectious, contagious, communicable or dangerous diseases (official text, Missouri Secretary of State; last amended effective February 28, 2023)
• 42 CFR §418.58 and §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.