Infection Prevention and Control

Section 300.696  Infection Prevention and Control a) A facility shall have an infection prevention and control program for the surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases. The program shall be under the management of the facility’s infection preventionist who is qualified through education, training, experience, or certification in infection prevention and control. b)         Written policies and procedures for surveillance, investigation, prevention, and control of infectious agents and healthcare-associated infections in the facility shall be established and followed, including for the appropriate use of personal protective equipment as provided in the Centers for Disease Control and Prevention’s Guideline for Isolation Precautions, Hospital Respiratory Protection Program Toolkit, and the Occupational Safety and Health Administration’s Respiratory Protection Guidance.  The policies and procedures must be consistent with and include the requirements of the Control of Communicable Diseases Code, and the Control of Sexually Transmissible Infections Code. 1)         All staff shall be trained at least annually on basic infection prevention and control practices based on job responsibilities.  Training records shall be maintained for three years.  For the purposes of this Section, “staff” means those individuals who work in the facility on a regular (that is, at least once a week) basis, including individuals who may not be physically in the facility for a period of time due to illness, disability, or scheduled time off, but who are expected to return to work.  This also includes individuals under contract or arrangement, including hospice and dialysis staff, physical therapists, occupational therapists, mental health professionals, or volunteers, who are in the facility on a regular basis. 2)         Students enrolled in accredited health care training programs who are providing direct care during internships or clinical rotations must have completed infection prevention and control training prior to working in the facility.  The facility shall ensure access to documentation of completed infection prevention and control training for all interns and students and provide a copy of this record upon request by the Department. 3)         Facility activities shall be monitored on an ongoing basis by the Infection Preventionist to ensure adherence to all infection prevention and control policies and procedures. 4)         Infection prevention and control policies and procedures shall be maintained in the facility and made available upon request to facility staff, the resident and the resident’s family or resident’s representative, the Department, the certified local health department, and the public. c)         A group, e.g., an infection prevention and control committee, quality assurance committee, or other facility entity, shall periodically, but no less than annually, review the measures and outcomes of investigations and activities to prevent and control infections, documented by written, signed, and dated minutes of the meeting. d)         Each facility shall adhere to the following guidelines and toolkits of the Centers for Disease Control and Prevention, United States Public Health Service, Department of Health and Human Services, Agency for Healthcare Research and Quality, and Occupational Safety and Health Administration (see Section 300.340): 1)         Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2)         Guideline for Hand Hygiene in Health-Care Settings 3)         Guidelines for Prevention of Intravascular Catheter-Related Infections 4)         Guideline for Prevention of Surgical Site Infection 5)         Guidelines for Preventing Healthcare-Associated Pneumonia 6)         Guideline for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings 7)         Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services 8)         The Core Elements of Antibiotic Stewardship for Nursing Homes 9)         The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use 10)       Nursing Home Antimicrobial Stewardship Guide 11)       Toolkit 3.  Minimum Criteria for Common Infections Toolkit 12)       TB Infection Control in Health Care Settings 13)       Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes 14)       Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) 15)       Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators 16)       Respiratory Protection Guidance for the Employers of Those Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities During the COVID-19 Pandemic 17)       Guidelines for Environmental Infection Control in Health-Care Facilities e)         The facility shall establish an infection prevention and control program (IPCP) that includes, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. f)         Infectious Disease Surveillance Testing and Outbreak Response 1)         The facility shall have a testing plan and response strategy in place to address infectious disease outbreaks.  Pursuant to the plan and response strategy, the facility shall test residents and facility staff for infectious diseases listed in Section 690.100 of the Control of Communicable Diseases Code in a manner that is consistent with current guidelines and standards of practice. 2)         Each facility shall conduct testing of residents and staff for the control or detection of infectious diseases when: A)        The facility is experiencing an outbreak; or B)        Directed by the Department or the certified local health department where the chance of transmission is high, including, but not limited to, regional outbreaks, epidemics, or pandemics.  For the purposes of this Section, “outbreak” has the same meaning as defined in the Control of Communicable Diseases Code. 3)         Documentation A)        For residents, document in each resident’s record any time a test was completed, including the result of the test, or whether testing was refused or contraindicated. B)        For facility staff and volunteers, maintain a testing log documenting any time a test was completed, including the result of the test, or whether testing was refused or contraindicated.  The testing log shall include all facility staff and volunteers. 4)         Upon confirmation that a resident, staff member, volunteer, student, or student intern tests positive with an infectious disease, or displays symptoms consistent with an infectious disease, each facility shall take immediate steps to prevent the transmission by implementing practices that include but are not limited to cohorting, isolation and quarantine, environmental cleaning and disinfecting, hand hygiene, and use of appropriate personal protective equipment. 5)         Each facility shall have written procedures for addressing residents, staff members, volunteers, students, and student interns who refuse testing or are unable to be tested. 6)         Each facility shall make arrangements with a testing laboratory to process any specimens collected under subsection (f) and shall ensure complete information for the individual being tested is submitted with each specimen as required by the laboratory requisition form. 7)         For testing done under subsection (f), each facility shall report to the Department, on a form and manner as prescribed by the Department, the number of residents, staff members, volunteers, students, and student interns tested, and the number of positive, negative, and indeterminate cases. g)         Certified facilities shall comply with 42 CFR 483.80(h). h)         Facilities shall not restrict visitation without a reasonable clinical or safety cause and shall facilitate in-person visitation whenever feasible, in accordance with Department and CDC guidance for infection prevention.