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Almost 200 years ago, physicians discovered that deadly pathogens were transmitted from patient to patient via the hands of nurses and physicians, and that washing hands between appointments with patients would dramatically reduce the mortality rate (World Health Organization, 2009). While tremendous strides in hand hygiene compliance have been made since the 19th century, there is still room for improvement—as the Centers for Medicare & Medicaid Services (CMS) noted during its Call with Nursing Homes on May 13, 2020 (CMS, 2020). The CMS Northeast Division Director for Survey and Reinforcement named three areas of practice that surveyors have noted need improvement, and hand hygiene was at the top of the list.
Factors Affecting Compliance with Hand Hygiene
Properly washing hands and performing hand hygiene is an essential skill every healthcare worker (HCW) must possess. The AAPACN Hand Hygiene Competency Tool can assist nurse leaders documenting achievement of competence with this skill. However, competence does not necessarily translate into compliance.
A systematic review of the research studying hand hygiene of HCW in the hospital setting found several factors affect compliance (Erasmus, et. al, 2010). While the nursing home setting is unique and poses different challenges from the acute care setting, the findings from this study can enlighten the Infection Preventionist (IP) and other nurse leaders as to factors they may consider when working toward improving hand hygiene compliance in the nursing home. See the table below for some helpful factors to consider.
The Centers for Medicare & Medicaid Services (CMS) most likely will specify education and training requirements for trauma-informed care under F741 (sufficient/competent staff‐behavioral health needs) and/or F949 (behavioral health training) in the upcoming revised Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” in the State Operations Manual—a revision that is now expected to be released in the second quarter of calendar year 2020, according to Quality, Safety, and Oversight (QSO) memo QSO-20-03-NH.
When they arrive, those requirements may not be too onerous because many staff members already should have skills that will translate across to trauma-informed care, such as knowing how to de-escalate and how to work with residents who have memory impairments, says Jill Schumann, MBA, president and CEO of LeadingAge Maryland in Baltimore and co-author of the Foundations of Trauma-Informed Care Toolkit and Implementing Trauma-Informed Care: A Guidebook.
Regardless of the exact requirements that CMS deems necessary, focusing on the following elements will help directors of nursing services (DNSs) and other members of the management team to implement effective trauma-informed care:
The July 2019 Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency Proposed Rule would give Medicare- and Medicaid-certified nursing homes a break by postponing the Requirements of Participation’s Phase 3 rollout of the training requirements at §483.95(d) in the Code of Federal Regulations (CFR), which is F944 (QAPI Training), as well as §483.95(f)(1) and (2), which is F946 (Compliance and Ethics Training). However, this November 28, providers still must have staff training in place to meet multiple new F-tag requirements under CFR §483.95 (Training Requirements):
F940 (Training Requirements – General);
F941 (Communication Training);
F942 (Resident’s Rights Training);
F945 (Infection Control Training);
F947 (Required Inservice Training for Nurse Aides). Note: While most of F947 has already been implemented, the component related to §483.95(g)(3) will implement in Phase 3. This requires that inservice training for nurse aides “address areas of weakness as determined in nurse aides' performance reviews and facility assessment at §483.70(e) and may address the special needs of residents as determined by the facility staff”; and
F949 (Behavioral Health Training).
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