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.

"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). This policy is that program for Sample Agency, LLC (the "Agency"). It also carries out the Agency's duties as a health care facility under 28 Pa. Code Chapter 27 and as a generator of regulated medical waste under 25 Pa. Code Chapter 284.

This policy applies to all care and services the Agency provides, in every setting, and to all supplies, equipment and waste the Agency handles.

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

The Agency:

• follows "accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions" (42 CFR §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 (QAPI) program and includes a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention (42 CFR §418.60(b));
• provides infection control education to employees, contracted providers, patients, and family members and other caregivers (42 CFR §418.60(c));
• reports reportable diseases, infections and conditions and outbreaks to the Department of Health as 28 Pa. Code Chapter 27 requires (Section 10); and
• handles sharps and regulated medical waste as 25 Pa. Code Chapter 284 and the OSHA bloodborne pathogens standard require (Section 12; Policy PA-HSP-IC-02).

No Pennsylvania rule requires a hospice to name an infection preventionist. The clinical manager leads the program, or designates in writing an RN with infection prevention training to do so. The lead keeps the program current with CDC guidance, reviews infection data monthly, reports to the QAPI program at least quarterly through Lee Sample, Quality program lead, and advises staff on precautions for individual patients. This structure is the Agency's standard.

• Hand hygiene. Staff clean their hands with an alcohol-based hand rub, or with soap and water when hands are visibly soiled or after caring for a patient with diarrhea, before and after patient contact, before a clean or sterile task, after contact with body fluids, after removing gloves, and after touching the patient's surroundings.
• Personal protective equipment (PPE). Gloves, gowns, masks, respirators and eye protection are supplied at no cost and worn according to the task and the precautions in place, and removed and discarded before leaving the patient's room or home.
• Respiratory hygiene. Staff with respiratory symptoms do not make visits (Section 7). Patients and families with coughs are offered masks and taught cough etiquette.
• Safe injection practices. One needle, one syringe, one time; single-dose vials for one patient only; no reuse of sharps.
• Bag technique. The nursing bag is placed on a clean barrier or kept in the car, hands are cleaned before going into the bag, and no used item goes back into the bag unless it has been cleaned and disinfected.
• Equipment. Reusable equipment such as stethoscopes and blood pressure cuffs is cleaned and disinfected with an EPA-registered disinfectant after each patient, according to the product's contact time. Single-patient items stay in the home.
• Transmission-based precautions. When a patient has or may have an infection that needs contact, droplet or airborne precautions, the RN case manager records the precautions in the plan of care and on the aide care instructions, and tells every staff member before the next visit. For airborne precautions staff wear a fit-tested N95 or higher respirator under the Agency's respiratory protection program (29 CFR §1910.134).
• Tuberculosis at home. A patient with suspected or confirmed infectious tuberculosis who is isolated at home is taught to cover the mouth and nose when coughing and sneezing and to handle and dispose of sputum carefully (28 Pa. Code §27.161), and the RN case manager cooperates with the isolation and contact testing the Department or local health authority directs.
• Devices. Staff follow the Agency's procedure manual for urinary catheters, IV lines, wounds and feeding tubes to reduce infection risk.

• Persons with amebiasis, enterohemorrhagic E. coli, shigellosis, typhoid or paratyphoid fever, hepatitis A, viral hepatitis or jaundice of unspecified etiology, or persistent diarrhea "may not work as health care practitioners who provide direct patient care" until the conditions in 28 Pa. Code §27.155 are met, for example negative stool specimens verified by a physician, or the stated time after onset. As the Agency's standard, the same restrictions apply to hospice aides, homemakers, volunteers and every other person in direct patient contact.
• As the Agency's standard, staff who have a fever, vomiting, diarrhea, a draining skin lesion, conjunctivitis or a respiratory illness with fever tell the scheduler before visiting and do not make visits until the infection control lead, applying current CDC guidance and any physician clearance, approves their return.
• As the Agency's standard, following CDC recommendations for health care personnel, staff with patient contact complete baseline tuberculosis screening (an individual risk assessment, a symptom evaluation and a TB test) before their first patient contact, and annual TB education. Testing after a known exposure is arranged at no cost to the employee. A household or other close contact of a person with infectious tuberculosis is required by 28 Pa. Code §27.161 to have the testing that section describes, and the Agency cooperates with any contact investigation.
• The Agency offers influenza vaccine to employees each year, and makes hepatitis B vaccination available under Policy PA-HSP-IC-02.
• Staff who have an exposure to blood or body fluids follow Policy PA-HSP-IC-02.

Agency nurses give immunizations or tuberculin skin tests to staff or patients only as the Board of Nursing rules allow:

• an RN only if a written order has been issued by a licensed physician, which may be a standing order, and the policies and procedures under which the RN may do so "have been established by a committee representing the nurses, the physicians and the administration of the agency or institution" (49 Pa. Code §21.16(a)). The Agency's committee is the medical director, the clinical manager and the Administrator. It identifies the agents, contraindications and treatment of possible anaphylactic reactions and the instruction and supervised practice required (§21.16(a)(2)(i)-(iv)); and
• an LPN only after completing a Board-approved educational program for immunizations and skin testing, under a physician's written order, and under the same committee policies, of which the LPN is given a current copy at least once every 12 months (49 Pa. Code §21.145(e)).

• Any staff member who notices signs or symptoms of an infection reports them to the RN case manager the same day. The RN assesses the patient, tells the physician and obtains orders.
• The RN records each infection acquired while receiving services on Form PA-HSP-IC-01-A: the date detected, the patient, primary diagnosis, signs and symptoms, type of infection, organism if identified, device involved, treatment and outcome (Agency standard).
• The infection control lead reviews the log each month for trends by infection type, device, staff member and setting, and investigates any cluster.
• Findings and actions are reported to the QAPI program, which approves a plan for actions that are expected to result in improvement and disease prevention and tracks whether they work (42 CFR §418.60(b); Policy PA-HSP-QA-01).
• An outbreak, or a communicable disease affecting several patients or staff, is reported to the Administrator at once and may be handled under Policy PA-HSP-EP-01.

A health care facility "is required to report a case of a disease, infection or condition" listed in 28 Pa. Code §27.21a(b) if it treats or examines a person who is suffering from, or who it suspects because of symptoms or appearance of having, a reportable disease, infection or condition (28 Pa. Code §27.21a(a)). The Agency reports as follows.

• The infection control lead keeps with this policy the current list in §27.21a(b) and checks it at each review of this policy.
• When an Agency clinician treats or examines a patient who has, or who the clinician suspects of having, a reportable condition, the clinician tells the infection control lead the same day. The lead reports the case for the Agency unless the Agency has reported the case previously (§27.21a(a)(1)). Influenza is reported only when confirmed by laboratory evidence of the causative agent (§27.21a(a)(2)). The lead applies the other exceptions in §27.21a(a), including those for cancer and AIDS, and asks the Department when unsure.
• Conditions in §27.21a(b)(1), such as measles, meningococcal invasive disease, Haemophilus influenzae invasive disease, Legionellosis and enterohemorrhagic E. coli, are reportable within 24 hours after being identified by symptoms, appearance or diagnosis. Conditions in §27.21a(b)(2), such as tuberculosis (suspected or confirmed active disease), viral hepatitis, salmonellosis, shigellosis, Lyme disease, chickenpox and invasive group A streptococcal disease, are reportable within 5 work days.
• An outbreak is reported within 24 hours (28 Pa. Code §27.3(a)). A person required to report who suspects a public health emergency reports an unusual occurrence of a disease, infection or condition not otherwise reportable within 24 hours (§27.3(b)).
• A case is reported to the Department through the appropriate electronic disease surveillance system. A preliminary report may be made by telephone and must be followed by a formal report through that system (28 Pa. Code §27.4(a)-(b)). The Department's 24-hour line is 877-PA-HEALTH (877-724-3258), 24 hours a day, seven days a week.
• The lead records each report (date, time, condition, how reported, confirmation) on the infection log and cooperates with any investigation. A licensed facility that fails to comply with the Chapter 27 reporting provisions may have restrictions placed on its license (28 Pa. Code §27.6(b)).

The Agency provides infection control education to employees, contracted providers, patients, and family members and other caregivers (42 CFR §418.60(c)).

• Employees and contracted providers: at orientation, at least every 12 months (Agency standard), and when guidance changes, covering this policy, hand hygiene, PPE, precautions, cleaning, waste and sharps, work restrictions and Policy PA-HSP-IC-02.
• Volunteers: at orientation, covering hand hygiene, when not to visit, and what not to touch (Policy PA-HSP-VOL-01).
• Patients, families and caregivers: at admission and when needs change, covering hand hygiene, care of devices, cleaning, laundry, safe disposal of dressings and sharps, and signs of infection to report. The teaching is recorded.

Regulated medical waste is handled under 25 Pa. Code Chapter 284 and 29 CFR §1910.1030(d)(4).

• Sharps that Agency staff use are placed, immediately after use and without recapping, bending or breaking, in a sharps container that is rigid, tightly lidded and puncture resistant, as well as leakproof on the sides and bottom and kept upright (25 Pa. Code §284.413(a)-(b)). Containers are closed and replaced when about three-quarters full (Agency standard) and never overfilled.
• Items saturated or dripping with blood are placed in a fluorescent orange, orange-red or red bag (25 Pa. Code §284.411(c)), double-bagged and securely tied where bags are the only container (§284.413(d)). Regulated medical waste is not commingled with other waste in the same container (§284.412(c)).
• Before regulated medical waste is transported, the outermost container is labeled with the words "regulated medical waste", the universal biohazard symbol and the word "BIOHAZARD", and the date the container was full or sealed, whichever occurred earlier, as 25 Pa. Code §284.414 requires.
• Full containers brought to the office are stored in a secured, marked area that denies access to unauthorized persons and protects the waste from water, animals and insects (25 Pa. Code §284.412(a)), and are not stored for longer than 30 days from the date the container is full or sealed, whichever occurs earlier (§284.415(a)).
• The Administrator arranges collection by a method that Chapter 284 allows, such as a transporter licensed by the Department of Environmental Protection, records the method with this policy, and keeps every shipping record.
• Sharps and dressings that the patient or family use for the patient's own care are home self-care waste, which is excluded from the definition of infectious waste (25 Pa. Code §271.1). The nurse gives the patient and family verbal and written instructions on safe sharps disposal as local rules allow, and records the teaching.
• Gloves, wipes and dressings that are not saturated or dripping with blood are bagged securely and placed in the household trash.
• Spills of blood or body fluids are cleaned with gloves and an EPA-registered disinfectant (Policy PA-HSP-IC-02).

Accountability under this policy is allocated as follows.

The patient infection log, Chapter 27 reports, teaching records and sharps instructions are kept in the clinical record or the infection control file (Policy PA-HSP-REC-01). Waste shipping records are kept by the Administrator for at least three years (Agency standard). Education records and staff health records are kept in the personnel file, with health records kept confidential and separate (Policy PA-HSP-HR-04). Each quarter, as the Agency's standard, the infection control lead reports to the QAPI program on:

• infections acquired while receiving services, by type, with rates where numbers allow;
• investigations, actions taken and their results;
• Chapter 27 reports made;
• hand hygiene and bag technique observed during supervisory and competency visits; and
• completion of staff, volunteer and family education.

Training is delivered and recorded as follows. Frequencies marked as the Agency's standard are not set by rule.

This policy implements the following authorities.

• 42 CFR §418.60, infection control
• 42 CFR §418.58, quality assessment and performance improvement
• 35 P.S. §448.806(g)(2), Department hospice licensing under interim guidelines
• Disease Prevention and Control Law of 1955, 35 P.S. §521.1 et seq.
• 28 Pa. Code §§27.1, 27.3, 27.4, 27.6 and 27.21a, reporting of diseases, infections and conditions
• 28 Pa. Code §27.155, restrictions on health care practitioners; §27.161, special requirements for tuberculosis
• 49 Pa. Code §§21.16 and 21.145(e), immunizations and skin testing by nurses
• Solid Waste Management Act, 35 P.S. §6018.101 et seq.; 25 Pa. Code §271.1 (definitions) and §§284.411-284.415 (regulated medical waste)
• 29 CFR §1910.1030, bloodborne pathogens; 29 CFR §1910.134, respiratory protection

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 16 is amended, the amendment is recorded in this table and a new version of this policy is issued.