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 of Sample Agency, LLC (the "Agency") by preventing and controlling infections and communicable diseases, finding problems early, and acting on them as part of the Agency’s quality program.

This policy covers infection prevention and control in every setting where the Agency provides care, the Agency office, and any Agency inpatient facility.

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

"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). The Agency "must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions" (§418.60(a)), maintain "a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases" that is "an integral part of the hospice’s 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)).

The infection control lead plans the program each year with the QAPI lead, reviews surveillance data every month, investigates clusters, updates procedures when CDC guidance changes, decides on precautions for individual patients, and reports to the QAPI program at every meeting (Agency standard). The governing body receives the infection control report at least yearly as part of the QAPI report (Policy DC-HSP-QA-01).

Every staff member follows standard precautions with every patient (42 CFR §418.60(a)):

• Hand hygiene with alcohol-based hand rub or soap and water before and after patient contact, before clean or aseptic tasks, after contact with body fluids, after removing gloves and after touching the patient’s surroundings. Soap and water are used when hands are visibly soiled and after caring for a patient with diarrhea that may be infectious.
• PPE chosen for the task: gloves for contact with body fluids, mucous membranes or broken skin; gowns, masks and eye protection when splashes or sprays are likely (Policy DC-HSP-IC-02).
• Respiratory hygiene: staff with respiratory symptoms do not make visits (Policy DC-HSP-HR-05); patients and family members with coughs are offered masks and tissues.
• Safe injection practice: one needle and one syringe, one time; single-dose vials for one patient only; sharps into a sharps container at once.
• Transmission-based precautions are added when the nurse knows or suspects an infection that spreads by contact (for example C. difficile, scabies or a multidrug-resistant organism), droplets (for example influenza) or the airborne route (for example tuberculosis or measles), following current CDC guidance. The precautions and the PPE needed are written in the plan of care so every visitor uses them (Agency standard).

• The nursing bag is kept closed, placed on a clean barrier away from children and pets, and opened only after hand hygiene; items that have been in the home are cleaned before they go back in the bag (Agency standard).
• Reusable equipment such as stethoscopes, blood pressure cuffs and thermometers is cleaned with an EPA-registered disinfectant after each patient; for patients on contact precautions, dedicated equipment is left in the home (Agency standard).
• Staff teach families how to clean surfaces, launder soiled linen, store supplies, care for catheters and wounds, and dispose of waste safely.
• Aides are assessed at supervisory visits on "Complying with infection control policies and procedures" (42 CFR §418.76(h)(3)(iv); Policy DC-HSP-AIDE-01).

The program must include "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)(2)).

• Nurses record on Form DC-HSP-IC-01-A each patient infection that is new after admission or present on admission and needs treatment or precautions: urinary tract infection, respiratory infection including pneumonia, influenza and COVID-19, skin and wound infection, bloodstream or line infection, C. difficile, and colonization or infection with a multidrug-resistant organism (Agency standard).
• Staff illnesses that may be work-related or may spread to patients are recorded in the same log, without names, under Policy DC-HSP-HR-05.
• Each month the infection control lead counts infections, looks for clusters by type, staff member, location or facility, and compares with earlier months (Agency standard).
• When a problem is found, the lead investigates (practices, equipment, staff, contacts), writes an action plan, and the QAPI program tracks it until the data show improvement (42 CFR §418.60(b); §418.58).

District rules list the communicable diseases that must be reported to the Director of DC Health and how fast (22-B DCMR §201). "The physician, veterinarian, or other person in charge of a communicable disease case shall report the case to the Director within the period of time required and in the manner prescribed in § 201." (22-B DCMR §202.1).

The full current list is kept with this policy and checked against 22-B DCMR §201 every year. When a patient has or is suspected to have a reportable disease, the nurse tells the infection control lead and confirms with the attending or hospice physician that the case has been reported. Where the Agency is the person in charge of the case, or the disease is found among Agency patients or staff with no other reporter, the infection control lead reports it to DC Health on the approved form with the information in 22-B DCMR §202.9, using DC Health’s disease reporting channels published on its website (Agency standard). Any change in the location of a case is reported "within twenty-four (24) hours of the change" (§202.12). Deaths from the diseases in 22-B DCMR §214.1 are handled under Policy DC-HSP-DTH-01.

If two or more patients or staff have the same infection within a short period in a way that suggests spread (for example in one facility or on one nurse’s caseload), the infection control lead treats it as a possible outbreak: it is reported to DC Health as §201.1 requires for "An outbreak that may be of public health concern", the affected facility is told, precautions are strengthened, affected staff are restricted under Policy DC-HSP-HR-05, and the QAPI program follows the response (Agency standard). A large or emerging outbreak triggers the emerging infectious disease annex of the emergency plan (Policy DC-HSP-EP-01).

• Sharps used by staff go into a puncture-resistant sharps container at once (Policy DC-HSP-IC-02). The Agency supplies a sharps container to any home where sharps are used and teaches the family to keep it out of reach of children (Agency standard).
• Full containers are closed and disposed of through the Agency’s sharps disposal arrangement or as the supplier directs; staff do not carry loose sharps (Agency standard).
• Dressings and other household waste soiled with body fluids are bagged and placed in household trash unless they would release liquid blood when compressed, in which case staff handle them as regulated waste under Policy DC-HSP-IC-02.

Infection control education is given to "employees, contracted providers, patients, and family members and other caregivers" (42 CFR §418.60(c)). Staff and contractors receive it at orientation and every year (Policy DC-HSP-HR-01). Patients and families receive teaching at admission and when a new risk arises (for example a new catheter, wound or infection), recorded in the clinical record.

If the Agency provides inpatient care directly, the unit "must maintain an infection control program that protects patients, staff and others by preventing and controlling infections and communicable disease as stipulated in § 418.60" (42 CFR §418.110(j)), "must provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions" (§418.110(k)), and "must have available at all times a quantity of clean linen in sufficient amounts for all patient uses", handled, stored, processed and transported so as to prevent the spread of contaminants (§418.110(l)). The procedures are in Policy DC-HSP-FAC-03.

Each role named below carries the duties shown.

The program keeps the infection surveillance log, monthly analyses, investigation reports and action plans, notifiable disease reports, education records and the yearly program review for at least six years (Agency standard). Each quarter the lead observes hand hygiene and bag technique on a sample of visits and reports the results to the QAPI program (Agency standard).

All staff, contractors and volunteers receive infection control training at orientation and yearly, covering hand hygiene, PPE, precautions, bag technique, cleaning, respiratory hygiene and when not to work (Agency standard; Policy DC-HSP-HR-01). Nurses also receive training on the District’s reportable disease rules.

This policy implements the following authorities.

• 42 CFR §418.60, Infection control
• 42 CFR §418.58, Quality assessment and performance improvement
• 42 CFR §418.76(h)(3)(iv), Aide supervision: infection control
• 42 CFR §418.110(j)-(l), Inpatient unit: infection control, sanitary environment, linen
• 22-B DCMR §201, Communicable disease surveillance
• 22-B DCMR §202, Reporting occurrences
• 22-B DCMR §214, Deaths of affected persons
• 22-B DCMR §299, Definitions
• Centers for Disease Control and Prevention, infection control guidance for health care personnel (guidance, not a rule)

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.