Download Infection Control * The New CoPs for Critical Access Hospitals

Infection Control – The New Conditions of
Participation (CoPs) for Critical Access Hospitals
Building Leaders – Transforming Hospitals – Improving Care
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Our Speaker
Deb Kleinfeldt, MSN, RN
Education
• ADN-1980 from Jackson College in Jackson, Michigan
• BSN-2008 from Chamberlain College of Nursing, Downers Grove,
Illinois
• MSN-Nursing Education-2014-Walden University, Minneapolis,
Minnesota
Experience
• 28 years of hospital infection control/prevention experience
• Developed two hospital based IC programs and one for my home
health agency.
Current
• Northwest College-Nursing faculty for RN and LPN and CNA programs
•
Worked as a clinical instructor while working at Powell Hospital and
have been teaching at the college since 2009 full time or as adjunct
© HTS3 2016 |
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Deb Kleinfeldt MSN, RN
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Critical Access Hospitals must comply with Conditions of Participation
What are the Conditions of Participation for Infection Control
Specific Interpretive Guidelines related to:
◦
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Healthcare Associated Infection (HAI)
Special challenges in infection control
Ambulatory Care guidelines
Communicable Diseases
Bioterrorism
Surveillance and Corrective Action
Sanitary Environment
Mitigation of Risks
Surveyors List
Surveyors Hot Topics
Resources for you

Critical Access Hospitals (CAHs) are required to be in compliance with the
Federal requirements set forth in the Medicare Conditions of Participation
(CoP) in order to receive Medicare/Medicaid payment.

Certification of CAH compliance with the CoP is accomplished through
observations, interviews, and document/record reviews. The survey process
focuses on a CAH’s performance of organizational and patient-focused
functions and processes. The CAH survey is the means used to assess
compliance with Federal health, safety, and quality standards that will
assure that the beneficiary receives safe, quality care and services.

If an individual or entity (CAH) refuses to allow immediate access to
either a State Agency or CMS surveyor, the Office of Inspector General
(OIG) may terminate the CAH from participation in the
Medicare/Medicaid programs in accordance with 42 CFR 1001.1301.
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Quality
§ 485.641 periodic evaluation and quality assurance
All patient care services and other services affecting patient health and safety are
evaluated
Nosocomial infections and medication therapy are evaluated
The critical access hospital (CAH) takes appropriate remedial action to address
deficiencies found through the quality assurance program
The CAH documents outcome of all remedial action
The policies required include the following:
 A system for identifying, reporting, investigating and controlling
infections and communicable diseases of patients and personnel.
1.
This regulation requires the CAH to have a facility-wide system for identifying,
reporting, investigating and controlling infections and communicable diseases of
patients and personnel. (Be sure to have a definition of infection included in your
system policies).
2.
The National Institute of Allergy and Infectious Diseases (NIAID) defines infectious
disease as a disease caused by microbes that can be passed to or among humans by
several methods.(http://www.niaid.nih.gov/topics/microbes/pages/glossary.aspx)
3.
The CDC states a communicable disease as: “an illness caused by an infectious agent or
its toxins that occurs through the direct or indirect transmission of the infectious agent
or its products from an infected individual or via an animal, vector or the inanimate
environment to a susceptible animal or human host:
(http://www.cdc.gov/tb/programs/laws/menu/definitions.htm)
A Healthcare-associated infection (HAI) is one that develops in a patient who is cared
for in any setting where healthcare is delivered (e.g., acute care hospital, chronic care
facility, ambulatory clinic, dialysis center, surgical center, home) and is related to
receiving health care (i.e., was not incubating or present at the time healthcare was
provided). According to the CDC, healthcare-associated infections, i.e., infections that
patients acquire during the course of receiving treatment for other conditions within a
healthcare setting, are one of the top ten leading causes of death in the United States.
As you are developing policies include approved “expert” definitions that will reflect
your facility’s IC environment. Be sure to cite your experts in your policies too.

The CAH must provide and maintain a sanitary environment to avoid sources and transmission of
infections and communicable diseases. All areas of the CAH must be visibly clean and sanitary. This
includes all CAH departments and off-site locations.

The CAH is expected to have a designated individual who is qualified by education and/or experience and
who is responsible for the infection control program. This person must have education or experience in the
principles and methods for infection prevention and control.

The CAH’s program for prevention, control and investigation of infections and communicable diseases
must be conducted in accordance with nationally recognized infection control practices or guidelines, as
well as applicable regulations of other federal or state agencies. Examples of organizations that are
nationally recognized infection and communicable disease control guidelines, and/or recommendations
include: (See next slide).

Centers for Disease Control and Prevention (CDC)

Association for Professionals in Infection Control and Epidemiology (APIC)
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Society for Healthcare Epidemiology of America (SHEA)
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Association of perioperative Registered Nurses (AORN)
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The U.S. Occupational Health and Safety Administration (OSHA) also issues federal regulations
applicable to infection control practices.
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Multi-Drug Resistant Organisms (MDROs)

The prevention and control of MDROs is a national priority - one that requires that
all healthcare facilities and agencies assume responsibility and participate in
community-wide control programs.

MDROs are defined as microorganisms –predominantly bacteria – that are resistant
to one or more classes of antimicrobial agents. A notable example is methicillinresistant Staphylococcus aureus (MRSA), an MDRO pathogen which is transmitted
within and between healthcare facilities, as well as in the community setting.

CAHs are encouraged to have mechanisms in place for the early identification of
patients with targeted MDROs prevalent in their CAH and community, and for the
prevention of transmission of such MDROs.
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The ambulatory care setting, including emergency departments and outpatient
clinics, accounts for a growing number of patient health encounters.

Ambulatory care settings present unique challenges for infection control, because
patients remain in common areas for prolonged periods waiting to be seen by a
healthcare professional. Exam or treatment rooms are turned around quickly with
limited cleaning, and infectious patients may not be recognized immediately.

The CAH’s infection prevention and control program must be designed with these
ambulatory care setting challenges in mind. Assess the likely level of risk in its
various ambulatory care settings, including off-site settings, a CAH might
identify particular settings, like the emergency department where screening
for infectious is prudent. Then take appropriate control measures for those
individuals who may present risk for the transmission of infectious agents by
the airborne or droplet route.
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The CAH’s infection prevention and control program must be designed with
these ambulatory care setting challenges in mind including off-site
departments.
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Again, prevention measures should include prompt physical separation wherever
possible, implementation of respiratory hygiene/cough etiquette protocols, and/or
appropriate isolation precautions based on the routes of transmission of the
suspected infection.
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If a communicable disease outbreak occurs, an understanding of the epidemiology,
modes of transmission, and clinical course of the disease is essential for responding
to and managing the event. Among the infection control issues that may need to be
addressed are:
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Preventing transmission among patients, healthcare personnel, and visitors;
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Identifying persons who may be infected and exposed;
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Providing treatment or prophylaxis to large numbers of people; and
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Logistics issues (staff, medical supplies, resupply, continued operations, and capacity).
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Widespread pandemics present special challenges for CAH staffing, supplies, resupply, etc.
CAHs should work with local, State, and Federal public health agencies to identify likely
communicable disease threats and develop appropriate preparedness and response strategies.

CAH facilities would confront a set of issues similar to naturally occurring
communicable disease threats when dealing with a suspected bioterrorism event.
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A variety of sources offer guidance for the management of persons exposed to
likely agents of bioterrorism, including Federal agency websites:
◦ (e.g., http://www.ahrq.gov/prep; http://www.usamriid.army.mil/ ; http://www.bt.cdc.gov).
◦ See Reference page. And check your State agencies.

Because of the many similarities between man-made and naturally occurring
threats, an all-hazards approach to developing emergency response plans is
preferred, and CAHs are encouraged to work with their State and local emergency
response agencies to develop their plans.

The ICP needs to able to show how their facility manages a communicable
disease outbreak as well as a threat of bioterrorism. Please look over the
resources that cover this and plan with other department managers.
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The CAH must be prepared to prevent, control and investigate infections and
communicable diseases, the CAH’s program must include an active surveillance
component that covers both CAH patients and personnel working in the hospital.
◦
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Surveillance includes infection detection, data collection and analysis, monitoring, and evaluation of
preventive interventions.
The CAH must conduct surveillance on a facility-wide basis in order to identify
infectious risks or communicable disease problems at any particular location.
◦ This does not imply “total hospital surveillance,” but it does mean that CAHs must have reliable
sampling or other mechanisms in place to permit identifying and monitoring infections and
communicable diseases occurring throughout the CAH.
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The CAH must document its surveillance activities, including the measures
selected for monitoring, and collection and analysis methods.
◦ Surveillance activities must be conducted in accordance with recognized infection control surveillance
practices, such as, for example, those utilized by the CDC’s National Healthcare Safety Net (NHSN).
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Prevention of infections includes the proper maintenance of a sanitary environment.

The CAH must provide and maintain a sanitary environment to avoid sources and
transmission of infections and communicable diseases. All areas of the CAH must
be visibly clean and sanitary. This includes all CAH units and off-site locations.

The infection prevention and control program must include appropriate monitoring
of housekeeping, maintenance (including repair, renovation and construction
activities), and other activities to ensure that the CAH maintains a sanitary
environment.
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Examples of areas to monitor would include: food storage, preparation, serving and
dish rooms, refrigerators, ice machines, air handlers, autoclave rooms, venting
systems, inpatient rooms, treatment areas, labs, waste handling, surgical areas,
supply storage, equipment cleaning, etc.

Failure to maintain a clean environment would also be a deficiency related to
§485.623(b)(4), which requires the CAH to maintain clean and orderly premises.
The CAH must have policies and procedures in place to mitigate the risks that
contribute to healthcare-associated infections. They must incorporate infection control
techniques and standard precautions including, but not limited to:
 Hand Hygiene
 Respiratory Hygiene/Cough Etiquette
 Use of Transmission-Based Precautions such as: contact precautions, droplet
precautions, and airborne precautions
 Use of personal protective equipment (PPE) for healthcare personnel such as
gloves, gowns, masks, and respirators
 Safe work practices to prevent healthcare worker exposure to bloodborne
pathogens, such as safety needles and safety engineered sharps devices
 Safe medication preparation and administration practices include, but are not
limited to:
◦ Routine preparation of injectable medications takes place in a designated clean medication area that is
not adjacent to areas where potentially contaminated items are placed.
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Proper hand hygiene before handling medications;
Always disinfect a rubber septum with alcohol prior to piercing it;
Always using aseptic technique when preparing and administering injections;
Never enter a vial with a used syringe or needle;
Never administer medications from the same syringe to more than one patient,
even if the needle is changed;
Recognize that after a syringe or needle has been used to enter or connect to a
patient’s IV it is contaminated and must not be used on another patient or to enter a
medication vial;
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Never use medications labeled as single-dose or single-use for more than one
patient. This includes ampoules, bags, and bottles of intravenous solutions.
Exception: It is permissible to use medications that have been repackaged from a
previously unopened single-dose container if the repackaging has been done by a
pharmacy in a manner consistent with USP/NP Chapter <797> standards, and if the
repackaged medications have subsequently been stored consistent with USP <797>
and the manufacturer’s package insert, provided that each repackaged dose is used
for a single patient.

If multi-dose vials are used for more than one patient, they must not be kept or
accessed in the immediate patient treatment area. This is to prevent inadvertent
contamination of the vial through direct or indirect contact with potentially
contaminated surfaces or equipment that could then lead to infections in subsequent
patients. If a multi-dose vial enters the immediate patient treatment area, it must be
dedicated to that patient only and discarded after use.
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Never use bags or bottles of intravenous solution as a common source of supply for
more than one patient
Wear a surgical mask when placing a catheter or injecting material into the spinal
canal or subdural space
Never use insulin pens and other medication cartridges and syringes intended for
single-patient-use only for more than one person
Other safe care practices, include, but not limited to:
◦ Never use the same fingerstick device for more than one person
◦ Avoid sharing blood glucose meters if possible. If they must be shared, the device must be cleaned and
disinfected after every use, per manufacturer’s instructions. If the manufacturer does not specify how
the device should be cleaned and disinfected, it must not be shared.
◦ Policies to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before
use on another patient
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Policies to ensure that reusable patient care equipment is cleaned and reprocessed
appropriately before use on another patient are good to have

The CAH must train staff on infection control policies and practices pertinent to the
staff’s responsibilities and activities. For example, the CAH is expected to provide
role-specific education on proper hand hygiene, standard and transmission-based
precautions, asepsis, sterilization, disinfection, food sanitation, housekeeping, linen
care, medical and infectious waste disposal, injection safety, separation of clean
from dirty, as well as other means for limiting the spread of infections.

The CAH is also expected to provide education to patients and their visiting family
members/caregivers, when applicable, about precautions to take to prevent
infections.
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The CAH is expected to monitor compliance with all policies, procedures,
protocols, and other infection control program requirements and to conduct
program evaluation and revision of the program, when indicated.
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Survey Procedures §485.635(a)(3)(vi)
Verify that the CAH has designated a qualified individual to be responsible for the
infection control program.
Can the responsible individual demonstrate that the CAH’s program adheres to
nationally recognized practices or guidelines?
Is the environment sanitary throughout the CAH?
Do CAH staff employ standard precautions appropriately?
Do CAH staff employ safe infection control practices for preparing and
administering medications?
Does the CAH perform active surveillance to identify infections?
Can the responsible individual demonstrate how staff compliance with infection
control program requirements is assessed and what corrective actions are taken?
Can the responsible individual demonstrate that infection control incidents,
problems, and trends are analyzed and that corrective actions are taken and further
assessed?
Is there evidence of training of staff in infection control practices pertinent to their
roles?
Surveyor Worksheet for Infection Control
ELEMENT
Y
N
Centers for Medicare & Medicaid Services
Hospital Infection Control Worksheet
Section 1.A. Infection Prevention Program and Resources
1.A.1: The hospital has designated one or more individual(s) as its
Infection Control Officer(s).
1.A.2: The Hospital has evidence that demonstrates the Infection Control Officer(s) is qualified and
maintain(s) qualifications through education, training or certification related to infection control
consistent with hospital policy.
Proposed CAH CoPs: An individual who are qualified through education, training, experience, or
certification in infection prevention and control, are appointed by the governing body, or
responsible individual, as the Infection Preventionist / infection control professional responsible for
the infection prevention and control program and that the appointment is based on the
recommendations of medical staff leadership and nursing leadership.
1.A.3: The Infection Control Officer(s) can provide evidence that the hospital has developed
general infection control policies and procedures that are based on nationally recognized guidelines
and applicable state law.
Proposed CAH CoPs: The infection prevention and control program, as documented in its policies
and procedures, employs methods for preventing and controlling the transmission of infections
within the CAH and between the CAH and other healthcare settings.
1.A.4: The Infection Control Officer can provide an updated list of diseases reportable to the local
and/or state public health authorities.
1.A.5: The Infection Control Officer can provide evidence that hospital complies with the
reportable diseases requirements of the local health authority.
FINDINGS - COMMENTS
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Handwashing
Proper use of disinfecting agents
Surgery-sterilizations processes/procedures, instrument cleaning, temperature an
humidity, air exchanges, traffic, handling of specimens.
MDROs
Antibiotic Stewardship
◦ Antibiotic resistance is now a major issue confronting healthcare providers and their patients. Changing
antibiotic resistance patterns, rising antibiotic costs and the introduction of new antibiotics have made
selecting optimal antibiotic regimens more difficult now than ever before. Furthermore, history has
taught us that if we do not use antibiotics carefully, they will lose their efficacy. As a response to these
challenges,

**Any topic that is an area of needed improvement found through your IC Risk
Assessment, how you developed specific targets and what actions have been taken
to address each issue.
Risk Assessment
Annual Goals
Strategies to Reduce Infection Risk
Evaluation of Plan Effectiveness
Infection Control Goals based on Risk Assessment Example
Goal: Reduce risk of healthcare-associated infections for all patients,
employees and visitors
Target 1: Reduce catheter-associated urinary tract infections house wide by
10% below FY 2016 rate
Action Items
What
Who
When
Metric
Implement automatic
discontinue orders for
catheters based on
criteria approved by
the medical staff
1. Develop protocol based on
evidence-based data
2. Submit protocol to Nursing
Congress and Medical Staff for
review and approval
3. Educate medical staff and nursing
staff
4. Include as part of new orientation
for all nursing staff
5. Audit for compliance with
protocol
IC
Nurse
Nursing
Leaders
MEC
1. 1/16
95%
compliance
with protocol
within 60 days
of
implementation
2. 2/16
3. 3/16
4. 4/16
5. 4/16

Agency for Healthcare Research and Quality. (2017, Jan. 19). Public health emergency
preparedness.

Association for Professionals in Infection Control and Epidemiology. (2017, Jan. 19). Resources.
Retrieved

Retrieved from http://www.ahrq.gov/prep
from apic.org/resources
Centers for disease control and prevention. (2017, Jan. 20). Bioterrorism. Retrieved from
http://www.bt.cdc.gov

Centers for disease control and prevention. (2017, Jan. 19). Menu of definitions. Retrieved from
http://www.cdc.gov/tb/programs/laws/menu/definitions.htm

Federal Register. Antimicrobial stewardship. (2017, Jan. 25). Retrieved from
http://www.apic.org/Resources/Topic-specific-infection-prevention/Antimicrobialstewardship

Federal Register. (2017, Jan. 19). Retrieved from https://www.federalregister.gov/

National Institute for Allergies and Infectious Diseases. (2017, Jan. 19). Resources. Retrieved from
http://www.niaid.nih.gov/topics/microbes/pages/glossary.aspx

United States Army Medical Department. (2017, Jan. 20). US Army medical research institute of
infectious
diseases. Retrieved from http://www.usamriid.army.mil/
PRODUCTIVITY AND STAFFING MANAGEMENT
Friday, February 10, 2017
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TOOLS AND RESOURCES FOR SUCCESSFUL ADVANCED
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Thursday, February 16, 2017
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CREATING AN ENGAGED WORKFORCE IN CHANGING
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849000707
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PHYSICIAN ENGAGEMENT STRATEGIES FOR RURAL
HOSPITALS
Thursday, February 23, 2017
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Management
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449283331
COPS FOR CRITICAL ACCESS HOSPITALS: WHAT’S NEW
AND WHAT YOU NEED TO KNOW
Friday, March 3, 2017
12:00 PM - 1:00 PM CST
Hosted by: Carolyn St.Charles, RN, BNS, MBA
Regional Chief Clinical Officer
Registration Link:
https://attendee.gotowebinar.com/register/1947597211
332234499
If you have questions or would like a review
of your Infection Control program
Please contact me
Carolyn St.Charles
Regional Chief Clinical Officer
[email protected]
360-584-9868
© HTS3 2016 | Page 37