Throughout the new survey process that implements on Nov. 28, 2017, the entire survey team will observe for breaks in infection control. “Infection-control deficient practices will be observed if they are happening and identified and documented,” said officials with the Centers for Medicare & Medicaid Services (CMS) during the July 25 MLN National Provider Call on the Revised Interpretive Guidance for Nursing Homes and the New Survey Process. Note: Access the call slides, as well as the transcription and recording (when available) here. In addition, assigned surveyors will complete the mandatory Infection Control Facility Task at every Medicare- or Medicaid-certified nursing home.
The Infection Control Facility Task includes a review of five residents for influenza and pneumococcal immunizations. There are also a number of changes compared to existing survey procedures, which officials with CMS reviewed during the surveyor training video Infection Control.
“First, the revised Infection Control Facility Task prompts surveyors to observe the appropriate use of all personal protective equipment, not just the use of gloves. Second, surveyors must observe the care of a resident on transmission-based precautions [if in the facility] and determine the appropriate use of those precautions,” said officials.
“Third, surveyors must determine whether washing machines and dryers are used according to the manufacturer’s instructions for use and that staff are following instructions for detergents, rinse aids, and laundering directions. Fourth, [surveyors] assess policies and procedures for annual review and/or updating and the use of national standards,” they added. “Fifth, surveyors are to evaluate whether the facility has a surveillance plan that uses evidence-based surveillance criteria to define infections; the use of a data collection tool; and to whom and when communicable diseases, healthcare-associated infections [HAIs], and potential outbreaks must be reported. And lastly, [surveyors] review the facility’s antibiotic stewardship program for antibiotic-use protocols and a system to monitor antibiotic use.” Note: Soon CMS is expected to publicly release all facility tasks and critical element pathways that surveyors will follow in the new survey process.
Six key areas of compliance
CMS officials also discussed standards of practice as they relate to compliance for six key areas:
* Hand hygiene
CMS has added new interpretive guidance clarifying when staff performing hand hygiene during the care of residents with Clostridium difficile (CDI) or norovirus infection should use soap and water or alcohol-based hand rubs, said officials. “Our guidance language comes from the CDC [Centers for Disease Control and Prevention], the Society for Healthcare Epidemiology of America, and the Infectious Disease Society of America’s current recommendations to use soap and water instead of alcohol-based hand rubs during care of residents with CDI or norovirus infection specifically during outbreak periods or high rates of infection.”
The recommendation to use soap and water instead of alcohol-based hand rubs only during these instances is confusing to some clinicians, acknowledged officials. “The reason for this recommendation is that, while alcohol does not kill Clostridium difficile spores, it has been shown effective in reducing Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE). Studies have shown soap and water is more effective than alcohol-based hand rubs at removing Clostridium difficile spores from hands, yet it has not been shown to change CDI rates.”
Since alcohol-based hand rubs are effective in reducing rates of non-spore-forming pathogens, such as MRSA and VRE, the recommendation for use of alcohol-based hand rubs in non-outbreak settings of CDI was made, said officials. “In addition, according to the CDC, strict adherence to glove use is the most effective means of preventing hand contamination with Clostridium difficile spores as they have been shown to be difficult to remove even with thorough handwashing. Like the case with CDI, soap and water are recommended instead of alcohol-based hand rubs during outbreaks of norovirus.”
In all other clinical situations except when hands are visibly soiled, alcohol-based hand rubs should be used, said officials. “In summary, alcohol-based hand rub is recommended for the care of residents with CDI or norovirus infection during non-outbreak periods or low rates of infections, and handwashing with soap and water [is recommended] during outbreaks or high rates of infections. Hand-hygiene observations are part of the Infection Control Facility Task.”
* Transmission-based precautions
“These precautions should be used for residents with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens … for which additional precautions are needed to prevent transmission,” said officials. One example of this type of pathogen is carbapenem-resistant Enterobacteriacea (CRE).
The CDC’s 2007 Guideline for Isolation Precautions outlines when transmission-based precautions should be used for certain infections and conditions and is referenced in the F880 guidance, said officials. “Furthermore, the 2006 Management of Multidrug-Resistant Organisms in Healthcare Settings guideline, as well as the 2015 Facility Guidance for CRE Toolkit, are other resources.”
In nursing homes, decisions regarding resident placement and use of precautions should be made on a case-by-case basis, said officials. “First, the facility must assess the likely pathogen and transmission. Then the identification of resident risk factors that increase the likelihood of transmission must be factored into whether a resident needs to be placed on transmission-based precautions. For example, does a resident have a draining wound and a dressing that does not adequately contain drainage? Is incontinent of stool? Has uncontained secretions or excretions? Or cognitive deficits that affect compliance with infection control measures? The facility must balance infection risks to other residents in the room or facility and the potential for adverse psychological impact on the infected or colonized resident.”
When used appropriately, transmission-based precautions are not to be considered involuntary seclusion, stressed officials. “However, once the resident is no longer at risk of transmitting the infection, for example, the illness duration has passed and/or the resident can contain secretions, transmission-based precautions must be removed in order to avoid unnecessary involuntary seclusion.”
Officials shared this example: A resident who is colonized with VRE based on a urine culture, but who is continent and cognizant should not be placed on transmission-based precautions. However, this resident “should be instructed regarding, or as necessary assisted with, performing hand hygiene before leaving his or her room,” they noted. “Furthermore, transmission-based precautions should be the least restricting possible for the resident based on his or her clinical situation and used for the least amount of time. The observation of care for a resident on transmission-based precautions is included in the facility task.”
* Contact precautions
Recommendations for when to put on personal protective equipment (PPE) when providing care to a resident on contact precautions can be found in the 2007 Guideline for Isolation Precautions and are included in the F880 interpretive guidance, said officials.
“PPE, including gloves and a gown, must be put on upon entering the room or cubicle, that is before making contact with the resident or environment, [and] discarded upon exiting the room or cubicle,” said officials. “Then hand hygiene must be performed.” The use and discarding of PPE is included in the Infection Control Facility Task.
* Droplet precautions
“Droplet precautions are actions designed to reduce or prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, and involve the use of face masks,” said officials. The 2007 Guideline for Isolation Precautions includes guidelines for residents known to be infected with pathogens (e.g., influenza) transmitted by respiratory droplets generated by a resident who is coughing, sneezing or even talking.
“Many wonder when one should apply a facemask when caring for a resident on droplet precautions,” said officials. “The maximum distance for droplet transmission is currently unresolved. But the area of defined risk based on epidemiological findings is approximately 3 – 10 feet. In contrast to airborne pathogens, droplet-borne pathogens are generally not transmitted through the air over long distances.”
Staff should wear a surgical or procedural face mask upon room or cubicle entry, that is, within three feet of a resident with symptoms of a respiratory infection, particularly if fever is present, as recommended per droplet precautions,” said officials. “In addition, staff should wear eye protection (e.g., face shield or goggles) as indicated to prevent splashes and sprays. For residents with suspected or proven emerging pathogens such as avian or pandemic influenza, facilities should refer to appropriate websites such as the CDC’s for the most current recommendations on use of PPE.”
* Blood glucose meters
“The use of a blood glucose meter by more than one person without cleaning and disinfecting between uses puts persons at risk for infection or [can contribute] to the transmission of bloodborne pathogens such as the Hepatitis B virus. The majority of Hepatitis B outbreaks associated with blood glucose monitoring have occurred in long-term care facilities,” said officials.
So how should blood glucose meters and other point-of-care devices, such as INR [international normalized ratio] monitors, be cleaned and disinfected? “Ideally a resident should have a dedicated blood glucose meter, and if not available, then the blood glucose meter is cleaned and disinfected using the recommended EPA-registered disinfectant per the manufacturer’s instructions for multi-patient use prior to another resident,” said officials. Note: Find disinfectants registered by the Environmental Protection Agency here.
The device should be cleaned and disinfected after every use to prevent carryover of blood and infectious agents, advised officials. “If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be used with other residents. Furthermore, the FDA [Food and Drug Administration] and CDC do not recommend alcohol for cleaning or disinfection of blood glucose meters regardless of manufacturers’ instructions. Seventy percent ethanol solutions are not effective against viral bloodborne pathogens, and the disinfectant used should be EPA-registered effective against HIV, Hepatitis B, and C.”
CMS officials highlighted a few ways that surveyors should assess laundry for compliance during the Infection Control Facility Task. “First, staff must use standard precautions for contaminated linen and hold contaminated linen in a laundry bag away from clothing during transport,” said officials. “For laundering, staff must maintain and use washing machines and dryers according to the manufacturer’s instructions for use, which includes the appropriate laundry weight and volume. If concerns are identified, [surveyors will] request evidence of washing machine and dryer maintenance logs.”
Staff must also follow laundering directions according to the linen and detergent manufacturers’ instructions for water temperature, machine cycle, and quantity of product for hygienically clean reprocessing, noted officials. “The facility is not required to monitor water temperatures during laundry processing cycles unless specified by state requirements. A chlorine bleach rinse is not required for all laundry items processed in low-temperature washing environments due to the availability of modern laundry detergents that are able to produce hygienically clean laundry without the presence of chlorine bleach.”
Here’s a new severity level four example for F880: “A resident was observed to have an acute onset of vomiting and diarrhea, which resulted in soiled clothing and linens. The nursing staff rinsed out the contaminated clothing and linens in the bathroom sink. The resident’s roommate, who also uses that sink, utilized it for oral hygiene. She herself then developed vomiting and diarrhea in addition to severe dehydration requiring hospitalization,” said officials. “This is an example of failing to handle soiled linens with a safe and sanitary technique that rose to the level of immediate jeopardy.”
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