Infection Prevention and Control Program and Medical Waste

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 makes sure that Sample Hospice, LLC (the "Agency") maintains and documents an effective infection control program that protects patients, families, visitors and Agency personnel by preventing and controlling infections and communicable diseases (26 TAC §558.853(a); 42 CFR §418.60), and that it meets the Texas requirements for infection control policies, infection documentation and medical waste (26 TAC §§558.285-558.286).

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 maintains and documents an effective infection control program that protects patients, families, visitors and Agency personnel by preventing and controlling infections and communicable diseases (26 TAC §558.853(a); 42 CFR §418.60). The Agency:

• follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions (26 TAC §558.853(b); 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 that includes a method of identifying infectious and communicable disease problems and a plan for implementing appropriate actions expected to result in improvement and disease prevention (26 TAC §558.853(c); 42 CFR §418.60(b));
• provides infection control education to employees, volunteers, contract staff, patients, and family members and other caregivers (26 TAC §558.853(d); 42 CFR §418.60(c));
• ensures that the Agency, its employees and its contractors comply with Texas Health and Safety Code Chapter 81 (communicable diseases), the OSHA Bloodborne Pathogens standard at 29 CFR §1910.1030 and its Appendix A, and Texas Health and Safety Code Chapter 85, Subchapter I, concerning the prevention of the transmission of HIV and hepatitis B virus (26 TAC §558.285(1)); and
• documents infections that patients acquire while receiving services (26 TAC §558.285(2)(A)), and handles biohazardous waste and sharps safely (26 TAC §558.286).

The supervising nurse leads the infection control 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 Committee at least quarterly, 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 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.
• 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 the Agency supplies the PPE needed.
• Devices. Staff follow the Agency’s procedure manual for urinary catheters, intravenous lines, wounds and feeding tubes to reduce infection risk.

• Staff who have a fever, vomiting, diarrhea, a draining skin lesion, conjunctivitis or a communicable illness tell the scheduler before visiting and do not make visits until they meet the CDC return-to-work guidance the infection control lead applies.
• The Agency offers influenza vaccine to employees each year and may give it under a physician’s standing order meeting 26 TAC §558.303(2). Hepatitis B vaccination is offered under Policy TX-HSP-IC-02.
• As the Agency’s standard, following CDC recommendations for health care personnel, staff with patient contact receive baseline tuberculosis screening before their first patient contact.
• Staff who have an exposure to blood or body fluids follow Policy TX-HSP-IC-02.

1. Any staff member who notices signs or symptoms of an infection reports it to the RN case manager the same day. The RN assesses the patient, tells the practitioner and obtains orders.
2. The RN records each infection the patient acquires while receiving services on Form TX-HSP-IC-01-A. The record includes the date the infection was detected, the patient’s name, primary diagnosis, signs and symptoms, type of infection, pathogens identified and treatment (26 TAC §558.285(2)(A)).
3. The infection control lead reviews the log each month for trends by infection type, device, staff member and setting, and investigates any cluster.
4. Findings and actions are reported to the QAPI Committee, which approves a plan for implementing actions expected to result in improvement and disease prevention, and tracks whether they work (26 TAC §558.853(c); Policy TX-HSP-QA-01).
5. An outbreak, or a communicable disease affecting several patients or staff, is reported to the Administrator at once and may be handled under Policy TX-HSP-EP-01.

Texas Health and Safety Code Chapter 81 and the Department of State Health Services (DSHS) rules require certain diseases and conditions to be reported to the local health authority or DSHS, within the time frame DSHS sets for each condition. When an Agency nurse learns that a patient has a notifiable condition that has not already been reported by a physician or laboratory, the nurse tells the infection control lead the same day, and the lead checks the current DSHS list and makes any report required. The report is recorded on the infection log.

The Agency provides infection control education to employees, volunteers, contract staff, patients, and family members and other caregivers (26 TAC §558.853(d); 42 CFR §418.60(c)).

• Employees and contract staff: at orientation, at least yearly, and when guidance changes, covering this policy, hand hygiene, PPE, precautions, cleaning, waste and sharps, and Policy TX-HSP-IC-02.
• Volunteers: at orientation, covering hand hygiene, when not to visit, and what not to touch (Policy TX-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.

This section is the Agency’s written policy for the safe handling and disposal of biohazardous waste and materials (26 TAC §558.286(a)).

• Special or medical waste that the Agency generates while providing care is disposed of according to 25 TAC Chapter 1, Subchapter K (26 TAC §558.286(b)). Agency sharps containers and regulated waste are returned to the office in a closed, labeled, puncture-resistant container carried in the trunk or cargo area, and collected by the Agency’s licensed medical waste contractor.
• Sharps are placed in a puncture-resistant, leak-proof, labeled sharps container immediately after use. Containers are replaced when about three-quarters full, as the Agency’s standard, and are never overfilled.
• The Agency gives every patient who uses sharps at home both verbal and written instructions on the proper procedure for disposing of sharps (26 TAC §558.286(b)). The nurse records that both were given.
• Soiled dressings and incontinence products that are not saturated with blood are bagged securely and placed in the household trash. Items saturated with blood are handled as regulated waste.
• Spills of blood or body fluids are cleaned with gloves and an EPA-registered disinfectant, following Policy TX-HSP-IC-02.

Accountability under this policy is allocated as follows.

The patient infection log, infection reports, notifiable condition reports, teaching records and sharps instructions are kept in the patient record or the infection control file (Policy TX-HSP-REC-01). Education records are kept in the personnel and volunteer files. Each quarter, as the Agency’s standard, the infection control lead reports to the QAPI Committee on:

• infections acquired while receiving services, by type, with rates where numbers allow;
• investigations and the actions taken and their results;
• 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.

• 26 Texas Administrative Code §558.853, Hospice Infection Control
• 26 Texas Administrative Code §558.285, Infection Control
• 26 Texas Administrative Code §558.286, Disposal of Special or Medical Waste
• 26 Texas Administrative Code §558.303(2), Vaccines and tuberculin
• Texas Health and Safety Code Chapter 81, Communicable Diseases
• Texas Health and Safety Code Chapter 85, Subchapter I, prevention of the transmission of HIV and hepatitis B virus
• 25 Texas Administrative Code Chapter 1, Subchapter K, Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities
• 42 CFR §418.60, Infection control
• 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 Hospice, 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 15 is amended, the amendment is recorded in this table and a new version of this policy is issued.