2/23/2017

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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

aimeef@qualishealth.org206-288-2567

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