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Preparing to Meet New Infection Prevention Requirements in Skilled
Nursing Facilities
Aimee Ford, Qualis HealthPatricia Montgomery, WA State Department of Health
Washington Health Care Association Winter ConferenceFebruary 24, 2017
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Qualis Health • A leading national population health
management organization
• The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington
The QIO Program • One of the largest federal programs dedicated to
improving health quality at the local level
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Objectives
• Review CMS’ key proposed changes to Infection Control requirements
• Identify the relationship between infection prevention and an overarching quality assessment, performance improvement (QAPI) approach
• Discuss key strategies for building a sustainable and robust infection prevention program
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Regulatory Changes for Nursing Homes
Source: https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
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Implementation In Three Phases
Phase I (November 28, 2016)
Phase II (November 28, 2017)
Phase III (November 28, 2019)
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42 CFR 483.80 Infection Control
• (a) Infection prevention and control program
• (b)Infection preventionist
• (c)IP participation on quality assessment and assurance committee
• (d)Influenza and pneumococcal immunizations
• (e)Linens
• (f)Annual review
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Other Pertinent Requirements483.35 Nursing Services: Need both sufficient and competent staffing based on resident population (Phase I)
483.70 Administration: SNF must conduct a Facility Assessment (Phase II) and review/update at least annually
483.75 Quality Assurance and Performance Improvement: Infection Preventionist must be a member of the QAA committee (Phase III)
483.95 Training requirements: Mandatory training on infection prevention (Phase III)
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§ 483.80(a) Infection Prevention and Control Program (IPCP)
a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to § 483.70(e) and following accepted national standards;
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(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
• (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;
• (ii) When and to whom possible incidents of communicable disease or infections should be reported;
• (iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
• (iv) When and how isolation should be used for a resident; including but not limited to:
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(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
(4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility.
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Risk Assessment
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§ 483.80(b) Infection Preventionist (IP)
The facility must designate one or more individual(s ) as the IP, who is responsible for the IPCP
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Primary training in nursing, medical technology, microbiology, epidemiology
Qualified by education, training, experience, or certification
Work at least part-time at the facility, and
Completed specialized training in infection prevention and control
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100%
10%
80%70%
40%
85%95%
46%
95% 91%
76%87%
0%
20%
40%
60%
80%
100%
Facility has anIP
IP is trained Reviewssurveillance
data andinfectionactivities
Has writtenevidence
basedinfection
preventionpolicies
Polices arereviewedannually
Facility haswritten
disaster plan
LTC
F r
epo
rtin
g c
om
plia
nce
Elements Assessed
Infection Control Program and Infrastructure ICAR assessments WA and CDC 12/2/2016
WA n=20
CDC n=264
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Infection Preventionist: The Current State
Hours Allocated• Median 8.5
hours
• Range 0-30 hours/week
Who?• Usually a Nurse
(RN,LPN) in LTC
• ADON
• Staff Development
• Employee Health
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IP Training and Education
• On-line webinars
• Local Chapter Meetings
• Network
• Equip for Long-Term Care
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APIC Training IDSA
http://www.idsociety.org/Infect_Control_Course/
http://www.apic.org/Education-and-Events/Course-Catalog/Course?id=0dd7229e-b200-4eaa-9f27-2357495ce66f
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Infection Prevention Compentency
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§ 483.80(c) Participation on the QAA Committee
“The individualdesignated as the IP, or at least one of the individuals…must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.”
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§ 483.80(d) Influenza and Pneumococcal Immunizations
Each resident is offered the immunization, unless medically contraindicated
Before offering the vaccine, each resident/representative receives education on its risks/benefits; this must be documented including whether the vaccine was/not received
Right to refuse immunization
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§ 483.80(e) Linens
“Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.”
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§ 483.80(f) Annual Review
“The facility will conduct an annual review of its IPCP and update their program, as necessary.”
The Current State of Infection Prevention in WA LTCF
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Infection Control Assessment and Response (ICAR)
ICAR assessments in Long‐term Care
Note:CDC timeline different from DOHNo other demographics provided
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100% 100% 100%
85%
100%
90%
80% 80%85%
50%
83%
94%99%
89%96%
100% 98%92%
85%82%
0%
20%
40%
60%
80%
100%
Has workexclusionpolicies
Personnelare
encouragedto reportillness
Conductsemployee
baseline TBscreening
Performs TBRisk
assessmentfor exposure
to TB
Offers HepB vaccine at
hire
Offersemployeeinfluenzavaccine
Tracksemployeevaccine
compliance
Has a BBPexposure
control plan
All receiveBBP training
at hire
All receivetraining at12 months
LT
CF
rep
ori
ng
co
mp
lian
ce
Elements Assessed
Healthcare Personnel SafetyICAR assessments WA and CDC 12/2/2016
WA n=20
CDC n=264
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70%
80%
70%75% 75%
90%85%
81%87%
76% 78% 76% 78%
88%
0%
20%
40%
60%
80%
100%
Has writtenadmission intakeprocedures to
identify potentiallyinfectious persons.
System notifysInfection Prevention
Coordinator ofMDROS (Lab or other
facility)
Has a writtensurveillance plan
outliningmonitoring/trackinginfections occurring
in residents.
Has system tofollow‐up on clinicalinformation when
residents aretransferred to acutecare hospitals formanagement of
suspected infections,including sepsis.
The facility has awritten plan for
outbreak responsewhich includes a
definition,procedures forsurveillance and
containment, and alist of syndromes orpathogens for which
monitoring isperformed.
Has a current list ofdiseases reportableto public healthauthorities.
Can provide point(s)of contact at the
local or state healthdepartment forassistance with
outbreak response.
LTCF reporting complian
ce
ElementsAssessed
Disease Surveillance and ReportingICAR assessments WA and CDC 12/2/2016
WA n=20
CDC n=264
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55%
70% 70%
25%
45%
60%
40%
50%
30%
15%
61%
53%
78%
26%
44%
56%
31%27% 29%
18%
0%
20%
40%
60%
80%
100%
Candemonstrateleadershipsupport forefforts toimprove
antibiotic use(antibiotic
stewardship).
Has identifiedindividuals
accountable forleadingantibiotic
stewardshipactivities
Has access toindividuals with
antibioticprescribing
expertise (e.g.ID trainedphysician orpharmacist).
Has writtenpolicies onantibioticprescribing
Hasimplementedpractices inplace toimprove
antibiotic use.
Has a reportsummarizingantibiotic usefrom pharmacydata createdwithin last 6months.
Has a reportsummarizingantibiotic
resistance (i.e.,antibiogram)from thelaboratory
created withinthe past 24months.
Provides clinicalprescribers
with feedbackabout theirantibioticprescribingpractices.
Has providedtraining on
antibiotic use(stewardship)to all nursingstaff within thelast 12 months.
Has providedtraining on
antibiotic use(stewardship)to all clinicalproviders withprescribingprivileges
within the last12 months.
LTCF reporting complian
ce
Elements assessed
Antibiotic StewardshipICAR assessments WA and CDC 12/2/2016
WA n=20
CDC n=264
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The verification of competency through the use of knowledge-based testing and direct observation.
If direct observation is not included, an alternative method to ensure that healthcare personnel possess essential knowledge, skills, and abilities should be used.
What Is Competency-Based Training?
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75
50
30
65
85
55
40
15
30
85
40
30
10
42
84
65 65
20
50
90
0
10
20
30
40
50
60
70
80
90
100
All personnel receivetraining and competencyvalidation at time of hire
All personnel receivetraining and competencyvalidation @ 12 months
The facility auditsadherence to practices
The facility providesfeedback to personnel
regarding theirperformance
Supplies and resourcesare available
% O
bser
ved
Com
plia
nce
Elements Assessed
Staff competency based training adherence
Hand Hygiene PPE Injection Safety Environmental Cleaning
Competency-Based Training Adherence
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Lessons from the ICAR ResultsStrengths• Has IP
• Has written disaster plan
• Reportable conditions list
• Evidence of beginning stewardship activities
• New Employee Orientation training
• Hand Hygiene Audits
Opportunities• IP Training
• Written policies and 12 month Review
• Written surveillance plan
• Offer and track employee influenza vaccine
• Training at 12 months
• Audits and Feedback
• Communication
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EQuIP Gap Survey vs. Infection Control and Response Assessments
Critical Access Hospital
Long‐term care
Critical Access Hospital
Long‐term care
Long‐term care
Healthcare is Complex!
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Influenza Season 2017…
• Staff and resident vaccination
• Identification of ill/ line list
• Treatment
• Chemoprophylaxis
• Decrease transmission• Isolation and Co-horting
• Hand hygiene/standard and transmission based precautions
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Did Your Infection Prevention System Work As Intended?
• Outbreaks reported in 167 facilities
• Median attack rate 11%
• Attack Rate Range
<2%-60%
• Employee Vaccine Coverage
• Median 63%
• 84 (50%) reporting
• Range 2%-100%
• Most common response “UNK”
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Leadership’s Role in Infection Prevention
Leadership is “a process whereby an individual influences a group of individuals to achieve a common goal”
(Northouse, P. (2016). “Leadership: Theory and Practice” SAGE Publications, 7th
edition)
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Take Home Points• SNFs are expected to develop and implement
a formal program designed to prevent infection
• The IPCP must be developed, implemented, and evaluated in a systematic fashion that sustains organizational changes
• Infection prevention and control is the job of a team, not an individual
• An effective IPCP begins with leadership commitment
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Q & A
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Action / Next Steps
What will you do with this information when you
return to your building?
What is one action
you can implement in one week?
What is one change you might try?
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References and Resources Advancing Excellence infection control toolkit: https://www.nhqualitycampaign.org/goalDetail.aspx?g=inf
Agency for Healthcare Quality and Research (AHRQ) Nursing Home Antimicrobial Stewardship Guide: http://www.ahrq.gov/nhguide/index.html
Centers for Disease Control (CDC) toolkit for long-term care facilities: http://www.cdc.gov/longtermcare/index.html
Centers for Disease Control (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
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Federal Emergency Management Agency (FEMA): Guide for All-Hazard Emergency Operations Planning https://www.fema.gov/pdf/plan/slg101.pdf
Federal Register Reform of Requirements for Long-Term Care Facilities (10/4/16): https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
S. Schweon, D. Burdsall, M. Hanchett, S. Hilley, D. Greene, I. Kenneley, J. Marx, P. Rosenbaum (2013).The Infection Perfectionist's Guide to Long-Term Care. Association for Professionals in Infection Control (APIC).
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Contact
Aimee Ford, MS, RNQI ConsultantQualis Health
Patty Montgomery, RN, MPH, CIC
Nurse ConsultantWashington State
Department of Healthpatricia.montgomery@doh.
wa.gov206-418-5558
For more information: www.Medicare.QualisHealth.org/cDiff
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-C2-QH-2803-02-17