Infection Control Brought to Annual Survey Process—How to Prepare Your Facility

By Emily Royalty-Bachelor, Staff Writer - December 07, 2017

It’s that time of year. The turkey has been carved and eaten, and the holiday decorations are beginning to appear. To most people, that means holiday season has officially arrived.

But to directors of nursing services (DNSs) across the country, it means something else entirely: the full implementation of Phase 2 of the Mega Rule—and with it, the new survey process to monitor compliance with infection control and prevention standards.

Is your facility ready for the surveyors? Here's how to get started to make sure that you meet the infection prevention requirements, and enjoy your holidays too.


The survey process

The infection control survey task was implemented nationwide on November 28, 2017, as part of the new standard survey process.

The survey team will ask for your infection prevention and control program (IPCP) standards and policies and procedures, Antibiotic Stewardship Program (ASP), and influenza/pneumococcal immunization policy and procedures within four hours of arrival.

All surveyors will observe for breaks in infection control during the survey. One surveyor will be assigned to coordinate and review the IPCP, the ASP, and immunizations. That surveyor will use the Infection Prevention, Control and Immunizations task, developed by the Centers for Medicare & Medicaid Services, to analyze infection prevention and control practices in the building and check that the staff is meeting the associated regulatory requirements.


Key takeaways from the survey task

Many of the items involved in the Infection Prevention, Control and Immunizations survey task are things that are almost certainly already implemented within your facility (although it would be wise to fully review the task and make sure you’re properly meeting all of these requirements).

Other task requirements, however, may be new to your facility, and may require some adjustment of your policies and procedures. Let’s break these down a bit further.


  1. Staffing

You may think when you hear the word staff that you know exactly what it means. Perhaps you think it means those people employed by the facility. Perhaps you think it means the nursing staff specifically. But neither assumption is correct. When referencing staff, the survey task means anyone who “provide(s) care and services to residents on behalf of the facility.” This includes employees, yes—but it also includes consultants, contractors, volunteers, and anyone else within the building who acts on behalf of the facility in any way.

“So when you look at implementing the infection control practices, it’s not just about the nursing staff protecting the residents from the infection. It's everyone in the building who could be exposed to infectious organisms or could be bringing them in and passing them on,” says Judi Kulus, MSN, MAT, RN, NHA, DNS-CT, RAC-MT and AADNS’s vice president of curriculum development.

It’s important to use this framework for the definition of staff when reviewing your policies and procedures in regard to this task. For instance, hand hygiene, protective equipment, and transmission-based precautions are often thought of within the context of nursing and other staff who may have direct hands-on interaction with the residents. But it’s also important to think of any other person, such as a member of laundry services, who may be coming into the facility with a cold or flu. It’s important that policies protecting the residents, like handwashing and precautions to prevent the transmission of disease, extend to all people who come and go within the facility.


  1. Meeting national standards

Page 4 of the survey task notes that your facility must have an IPCP with the following characteristics:

·         It is written with policies and procedures based on national standards.

·         The policies and procedures are current and are reviewed every year, at a minimum.

·         The policies and procedures are pertinent to prevention and management of infectious diseases within the facility.

If your policies and procedures regarding infection control haven’t been reviewed within the past year, review them now to make sure that they meet national standards. Update your policies and procedures with evidence-based standards by reviewing the guidelines established by the Centers for Disease Control and Prevention (CDC). You should also make sure that your policies and procedures are dated to reflect the fact that you’ve reviewed them within the past year and that they fully cover all items listed within the survey task.


  1. Infection surveillance based on facility assessment

An important concept under the task item “Infection Surveillance” is noted in the first bullet point:

“The facility has established/implemented a surveillance plan, based on a facility assessment, for identifying, tracking, monitoring and/or reporting of infections.”

The key takeaway here is that your surveillance plan needs to be based on a facility assessment. The facility assessment is a separate regulation (F838), wherein facility leaders identify types of diseases and conditions that are occurring among that facility’s particular resident population, and ensure that the residents’ needs are being met as they pertain to those specific diseases and infections.

The results of the facility assessment must be used, in part, to establish and update the IPCP and its policies and/or protocols to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, and visitors.

“Basically they have to review all of their residents in the facility and determine what type of care the residents need. So they need to be thinking about any infectious diseases that the residents might have, or might be exposed to, and how they might mitigate that based on the unique resident chance of exposure,” says Kulus.

Everyone’s facility assessment is going to be unique to that facility, since it will depend entirely on the particular resident population. This means that no two IPCPs will look exactly the same.

IPCPs might even be so tailored that facility leaders find that they have to decline admission to particular people if they can’t meet those individuals’ needs. For example, if a potential resident has a highly infectious disease that requires a negative pressure room, and the facility doesn’t have that feature, staff would not be able to take in the person because they would not be able to meet this need.


  1. An early detection warning system

When developing your infection surveillance plan, it’s important to have an early detection warning system, as noted in the second bullet point under “Infection Surveillance”:

The plan includes early detection, management of a potentially infectious, symptomatic resident and the implementation of appropriate transmission-based precautions.”

Early detection means being able to identify that more than one resident is acquiring a particular infectious disease, and recognizing early that there could be an outbreak beginning. It’s important to make sure your policies and procedures include a system for doing so.

“Early detection is a key concept,” says Kulus. “If something is spreading, like C. diff or a flu bug, they need to identify it quickly so they can mitigate the spread.”


  1. Evidence-based surveillance criteria

The third bullet point of the surveillance plan item concerns using evidence-based surveillance criteria, such as NHSN or McGeer criteria. These are used to (1) define infections that warrant surveillance and (2) provide protocols for response.

To establish their surveillance program, facility nurse leaders should work with the infection preventionist to evaluate the efficacy of each type of criteria, and make sure their program includes elements from within those protocols.

You can learn more about McGeer here and NHSN here.


  1. Specific care areas

It’s important to note that the program will be investigated under specific care areas on an as-needed basis.

The task reads: “If a specific care area concern is identified, it should be evaluated under the specific care area, such as for pressure ulcers, respiratory care, catheter care, and medication pass observations which include central lines, peripheral IVs, and oral/IM/respiratory medications.”

For example, if a resident acquired a pressure ulcer in the facility, staff need to follow accepted techniques in the process of caring for that pressure ulcer. If, during the course of treatment, the pressure ulcer becomes infected, the facility could be cited for Infection Control under the pressure ulcer critical element pathway.

Or if you have residents who use ventilators or have a tracheostomy, and, in the process of caring for those residents, staff members aren’t following proper technique and as a result are potentially spreading infection, your facility could be cited.

“These are some examples of care delivery activities or processes that, if not done properly, can contribute to the spread of infectious diseases. So as part of the infection control policies and procedures, facility leaders need to look at their facility-wide assessment to determine what types of care and disease processes their unique resident population has and make sure that, as part of the care processes, they have included guidance on how to perform the activities to prevent the spread of infection,” says Kulus.

There is more to the task, but Kulus says those are some of the most important concepts to be aware of. However, the Infection Prevention, Control and Immunizations task is just one of nine mandatory tasks that surveyors will be conducting as part of the annual survey process, so make a point of downloading and reviewing all of them to be sure you’re fully prepared for the annual survey process.

The American Association of Directors of Nursing Services offers the Antibiotic Stewardship Program in Long-Term Care Virtual Workshop.


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