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, staff and volunteers of Sample Agency, LLC (the "Agency") from infections and communicable diseases through prevention, surveillance, control and education.

This policy covers the infection control program and its leadership, prevention practices, cleaning and disinfection, medical waste, infection risk assessment, surveillance, outbreak investigation, communicable disease reporting and education, in patients' homes, facilities where patients live, the Agency's offices and any hospice residential or inpatient facility the Agency operates.

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

"Written policies shall be established and implemented by the agency regarding infection control and exposure to communicable diseases consistent with the rules set forth in 10A NCAC 41A, which is incorporated by reference, including subsequent amendments. These policies and procedures shall include provisions for compliance with 29 CFR 1910 Occupational Safety and Health Standards, which is incorporated by reference including subsequent amendments and editions. These editions shall include 29 CFR 1910.1030 Bloodborne Pathogens." (10A NCAC 13K .0401(a)). The Agency also has policies on "storage, preventive maintenance, and infection control of supplies and equipment" (10A NCAC 13K .0301(a)(10)).

If the Agency is Medicare-certified: "The hospice must maintain and document 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 must follow accepted standards of practice, including the use of standard precautions (§418.60(a)); maintain 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 assessment and performance improvement program (§418.60(b)); and provide infection control education to employees, contracted providers, patients, and family members and other caregivers (§418.60(c)).

1. The Director of Nursing (Robin Sample, RN) is responsible for the program and names the infection control lead (Agency standard).
2. The infection control policies are developed by the Administrator and the Medical Director and approved by the governing body, as 10A NCAC 13K .1106(b) requires for hospice residences; the Agency follows the same process for all its infection control policies (Agency standard).
3. The program follows accepted standards of practice, using current guidance from the Centers for Disease Control and Prevention (CDC) and the North Carolina Division of Public Health (42 CFR §418.60(a); Agency standard).
4. The infection control lead reports to the quality program every quarter (42 CFR §418.60(b)(1); Policy NC-HSP-QA-01).

Every staff member and volunteer uses standard precautions with every patient (42 CFR §418.60(a)). The specific practices are below.

• Staff clean their hands on arrival and before leaving the home, before and after touching the patient, before clean or aseptic procedures, after contact with blood or body fluids, after removing gloves, and after touching the patient's surroundings (Agency standard following CDC guidance).
• Alcohol-based hand rub is used unless hands are visibly soiled, after caring for a patient with diarrhea or a suspected spore-forming organism, or when the CDC calls for soap and water. Where there is no running water, staff use hand rub and antiseptic towelettes and wash with soap and running water as soon as feasible (29 CFR §1910.1030(d)(2)(iv)).
• Staff keep nails short and do not wear artificial nails when giving hands-on care (Agency standard).

• Staff carry and use gloves, gowns, masks, eye protection and face shields as the expected exposure requires. The Agency provides PPE at no cost to staff (29 CFR §1910.1030(d)(3)(i); Policy NC-HSP-IC-02).
• For a patient with a known or suspected transmissible infection, the nurse applies transmission-based precautions, writes them in the care plan and on the nurse aide's written assignment, and teaches the family (Agency standard).
• Staff with respiratory symptoms who are well enough to work wear a mask for patient contact (Policy NC-HSP-HR-05). Patients and family members with coughs are offered masks and tissues (Agency standard).
• Staff wear clean garments or protective clothing at all times and practice good personal hygiene and cleanliness, as 10A NCAC 13K .1106(d) requires in hospice residences; the Agency applies the same rule in every setting (Agency standard).

• Aseptic technique is used for injections, infusions, catheter insertion and care, and wound care (Agency standard).
• One needle, one syringe, one use; single-dose vials are used for one patient only (Agency standard following CDC safe injection practices).
• Indwelling urinary catheters are used only when the care plan states a reason, and are cared for to reduce infection (Agency standard).
• Sharps are handled under Policy NC-HSP-IC-02.

• The nursing bag is placed on a clean, dry surface or a barrier, never on the floor or bed. Hands are cleaned before reaching into the bag, and used items never go back into the clean part of the bag (Agency standard).
• Reusable equipment that touches the patient is cleaned and disinfected with an approved product before it goes back into the bag, following the manufacturer's contact time (10A NCAC 13K .0301(a)(10); Policy NC-HSP-DME-01).
• For a patient on contact precautions, the Agency leaves dedicated equipment (for example a stethoscope or blood pressure cuff) in the home where possible (Agency standard).

• Sharps used by staff go into a sharps container that is closable, puncture resistant, leakproof on sides and bottom and labeled or color-coded (29 CFR §1910.1030(d)(4)(iii)(A)(1)). Families who use sharps are taught to use a sharps container or a heavy plastic bottle with a screw cap, and how to dispose of it locally (Agency standard).
• Other waste soiled with blood or body fluids is bagged and disposed of in the household trash unless it is regulated waste, which is handled under Policy NC-HSP-IC-02 and the local rules for medical waste (Agency standard).
• Soiled linens are handled as little as possible, carried away from the body, and washed separately in hot water where the family can do so (Agency standard).
• Specimens are placed in a sealed, labeled bag and transported upright in a closed container (Agency standard; Policy NC-HSP-LAB-01).

1. At admission and in each assessment update, the nurse records the patient's infection risks (for example catheters, wounds, infusion devices, recent hospital stays, multidrug-resistant organisms, immune suppression) and conditions in the home that affect infection control (water, hygiene facilities, pests, waste disposal) (Agency standard; Policy NC-HSP-ASM-01).
2. Interventions are written into the care plan, and the family is taught what to do (42 CFR §418.60(c)).

1. The Agency has a method of identifying infectious and communicable disease problems (42 CFR §418.60(b)(2)(i)): nurses report every suspected or confirmed infection in a patient (for example urinary tract, respiratory, skin and wound, bloodstream and gastrointestinal infections, and multidrug-resistant organisms) to the infection control lead within one business day, and staff report their own reportable illnesses under Policy NC-HSP-HR-05 (Agency standard).
2. The infection control lead enters each case on the Infection Surveillance Log (Form NC-HSP-IC-01-A) with whether it appears related to hospice care (Agency standard).
3. The infection control lead reviews the log every month for patterns and clusters, and the review is recorded (Agency standard; 10A NCAC 13K .1106(e) requires monthly monitoring of the program in hospice residences, and the Agency applies it to the whole program).
4. Findings, and the plan for implementing the appropriate actions that are expected to result in improvement and disease prevention (42 CFR §418.60(b)(2)(ii)), are reported to the quality program each quarter.

1. When the log or a report suggests an outbreak, the infection control lead investigates the same day: who is affected, where, which staff had contact, and what practices may have contributed (Agency standard; 42 CFR §418.60(b)).
2. The Director of Nursing and the Medical Director decide the control measures (for example staff assignments, extra precautions, staff testing or exclusion from work) and contact the local health department for advice (Agency standard).
3. The Agency follows the local health department's instructions on investigation, testing, work restrictions and contact follow-up (Agency standard; Policy NC-HSP-HR-05).
4. Each investigation, the actions taken and the outcome are recorded and reviewed by the quality program (Agency standard).

1. The Agency's infection control policies are consistent with 10A NCAC 41A, which 10A NCAC 13K .0401(a) incorporates by reference. The Director of Nursing keeps a current copy of the North Carolina list of reportable diseases and conditions (Agency standard).
2. When a patient or staff member has a reportable communicable disease, the Agency confirms that the attending physician or laboratory has reported it to the local health department, and makes any report the rules require of the Agency itself. The Agency cooperates with the local health department in any investigation (Agency standard).
3. Staff with questions may call the NCDHHS communicable disease line, 919-733-3419 (24 hours a day, 7 days a week; NCDHHS assistance for clinicians and laboratories with communicable disease questions).

1. All staff providing direct patient and family services are trained in infection control as part of hospice training (10A NCAC 13K .0402(b)(11)). The Agency provides infection control education to employees, contracted providers, patients, and family members and other caregivers (42 CFR §418.60(c)).
2. Patients and caregivers are taught hand hygiene, care of devices, safe handling of sharps and soiled items, signs of infection to report, and any precautions the patient needs. The teaching is recorded in the clinical note (Agency standard).
3. Contracted providers receive the Agency's infection control expectations before their first visit (Agency standard; Policy NC-HSP-CON-01).

Once a year the infection control lead, the Director of Nursing and the Medical Director review the program: surveillance results, outbreaks, staff exposure incidents (Policy NC-HSP-IC-02), audits of hand hygiene and bag technique, staff vaccination rates, and changes in CDC or North Carolina guidance. The review is recorded and is part of the annual evaluation of the Agency (Agency standard; 10A NCAC 13K .1001; Policy NC-HSP-QA-01).

Each role named below carries the duties shown.

The infection control lead keeps the Infection Surveillance Log (Form NC-HSP-IC-01-A), the monthly reviews, outbreak investigations, practice audits and the annual program review. Training records are kept under Policy NC-HSP-HR-01. Patient teaching and precautions are recorded in the medical record.

Every staff member and volunteer providing direct patient and family services is trained in infection control at orientation and every year (10A NCAC 13K .0402(b)(11); annual frequency is the Agency standard), including hand hygiene, standard and transmission-based precautions, bag technique, cleaning of equipment, sharps and waste, and this policy. Hands-on staff also complete bloodborne pathogen training with annual updates (10A NCAC 13K .0401(e)(6); Policy NC-HSP-IC-02).

This policy implements the following authorities.

• 10A NCAC 13K .0301(a)(6), (10), required written policies
• 10A NCAC 13K .0401(a), (b), infection control; tuberculosis
• 10A NCAC 13K .0402(b)(11), infection control training
• 10A NCAC 13K .1001, annual evaluation
• 10A NCAC 13K .1106, infection control in hospice residences
• 10A NCAC 41A, communicable disease control (incorporated by 10A NCAC 13K .0401(a); cited, not quoted)
• 29 CFR §1910.1030, bloodborne pathogens
• 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.