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Infection Control – The New Conditions of Participation (

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Infection Control – The New Conditions of Participation (

Presentation on theme: "Infection Control – The New Conditions of Participation ("— Presentation transcript:


Infection Control – The New Conditions of Participation (CoPs) for Critical Access Hospitals Slide2

Turnaround Strategy


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Regulatory Compliance and Accreditation Preparation Lean Process ImprovementCommunity Health Needs Assessments

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Building Leaders – Transforming Hospitals – Improving CareSlide3

Instructions for Today’s WebinarYou may type a question in the text box if you have a question during the presentationWe will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail

You may also send questions after the webinar to Carolyn St.Charles (contact information is included at the end of the presentation)

The webinar will be recorded and the recording will be available on the HealthTechS3 web sitewww.healthtechs3.comHealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive.  HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof.  HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.Slide4

Our SpeakerDeb Kleinfeldt, MSN, RNEducationADN-1980 from Jackson College in Jackson, MichiganBSN-2008 from Chamberlain College of Nursing, Downers Grove,


MSN-Nursing Education-2014-Walden University, Minneapolis, MinnesotaExperience28 years of hospital infection control/prevention experienceDeveloped two hospital based IC programs and one for my home health agency. CurrentNorthwest College-Nursing faculty for RN and LPN and CNA programsWorked as a clinical instructor while working at Powell Hospital and have been teaching at the college since 2009 full time or as adjunctSlide5

Infection Control – The New Conditions of Participation (CoPs) for Critical Access Hospitals

Deb Kleinfeldt MSN, RNSlide6

Critical Access Hospitals must comply with Conditions of Participation What are the Conditions of Participation for Infection ControlSpecific Interpretive Guidelines related to:

Healthcare Associated Infection (HAI)

Special challenges in infection controlAmbulatory Care guidelinesCommunicable DiseasesBioterrorismSurveillance and Corrective ActionSanitary EnvironmentMitigation of RisksSurveyors ListSurveyors Hot TopicsResources for you

What We Will CoverSlide7

Critical Access Hospitals (CAHs) are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment.


of CAH compliance with the CoP is accomplished through observations, interviews, and document/record reviews. The survey process focuses on a CAH’s performance of organizational and patient-focused functions and processes. The CAH survey is the means used to assess compliance with Federal health, safety, and quality standards that will assure that the beneficiary receives safe, quality care and services. If an individual or entity (CAH) refuses to allow immediate access to either a State Agency or CMS surveyor, the Office of Inspector General (OIG) may terminate the CAH from participation in the Medicare/Medicaid programs in accordance with 42 CFR 1001.1301. CoPs and Critical Access HospitalsSlide8

Quality§ 485.641 periodic evaluation and quality assuranceAll patient care services and other services affecting patient health and safety are evaluated

Nosocomial infections and medication therapy are evaluated

The critical access hospital (CAH) takes appropriate remedial action to address deficiencies found through the quality assurance programThe CAH documents outcome of all remedial actionCMS Conditions of Participation (CoPs)Slide9

The policies required include the following:A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

This regulation requires the CAH to have a

facility-wide system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. (Be sure to have a definition of infection included in your system policies).The National Institute of Allergy and Infectious Diseases (NIAID) defines infectious disease as a disease caused by microbes that can be passed to or among humans by several methods.(http://www.niaid.nih.gov/topics/microbes/pages/glossary.aspx)The CDC states a communicable disease as: “an illness caused by an infectious agent or its toxins that occurs through the direct or indirect transmission of the infectious agent or its products from an infected individual or via an animal, vector or the inanimate environment to a susceptible animal or human host: (http://www.cdc.gov/tb/programs/laws/menu/definitions.htm)

Interpretive Guidelines §485.635(a) (3)(vi)Slide10

A Healthcare-associated infection (HAI) is one that develops in a patient who is cared for in any setting where healthcare is delivered (e.g., acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgical center, home) and is related to receiving health care (i.e., was not incubating or present at the time healthcare was provided). According to the CDC, healthcare-associated infections, i.e., infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting, are one of the top ten leading causes of death in the United States.

As you are developing policies include approved “expert” definitions that will reflect your facility’s IC environment. Be sure to cite your experts in your policies too.

Healthcare Associated Infection (HAI)Slide11

The CAH must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. All areas of the CAH must be visibly clean and sanitary. This includes all CAH departments and off-site locations.

The CAH is expected to have a

designated individual who is qualified by education and/or experience and who is responsible for the infection control program. This person must have education or experience in the principles and methods for infection prevention and control. The CAH’s program for prevention, control and investigation of infections and communicable diseases must be conducted in accordance with nationally recognized infection control practices or guidelines, as well as applicable regulations of other federal or state agencies. Examples of organizations that are nationally recognized infection and communicable disease control guidelines, and/or recommendations include: (See next slide).


Centers for Disease Control and Prevention (CDC)


for Professionals in Infection Control and Epidemiology (APIC)Society for Healthcare Epidemiology of America (SHEA)Association of perioperative Registered Nurses (

AORN)The U.S. Occupational Health and Safety Administration (OSHA) also issues federal regulations applicable to infection control practices. HAI-continued-Who to look to for infoSlide13

Multi-Drug Resistant Organisms (MDROs)

The prevention and control of MDROs is a national priority - one that requires that all healthcare facilities and agencies assume responsibility and participate in community-wide control programs.

MDROs are defined as microorganisms –predominantly bacteria – that are resistant to one or more classes of antimicrobial agents. A notable example is methicillin-resistant Staphylococcus aureus (MRSA), an MDRO pathogen which is transmitted within and between healthcare facilities, as well as in the community setting. CAHs are encouraged to have mechanisms in place for the early identification of patients with targeted MDROs prevalent in their CAH and community, and for the prevention of transmission of such MDROs.

Special Challenges in Infection ControlSlide14

The ambulatory care setting, including emergency departments and outpatient clinics, accounts for a growing number of patient health encounters.

Ambulatory care settings present unique challenges for infection control, because

patients remain in common areas for prolonged periods waiting to be seen by a healthcare professional. Exam or treatment rooms are turned around quickly with limited cleaning, and infectious patients may not be recognized immediately. The CAH’s infection prevention and control program must be designed with these ambulatory care setting challenges in mind. Assess the likely level of risk in its various ambulatory care settings, including off-site settings, a CAH might identify particular settings, like the emergency department where screening for infectious is prudent. Then take

appropriate control measures for those individuals who may present risk for the transmission of infectious agents by the airborne or droplet route. Ambulatory CareSlide15

The CAH’s infection prevention and control program must be designed with these ambulatory care setting challenges in mind

including off-site departments.

Again, prevention measures should include prompt physical separation wherever possible, implementation of respiratory hygiene/cough etiquette protocols, and/or appropriate isolation precautions based on the routes of transmission of the suspected infection. Ambulatory Care-continuedSlide16

Communicable Disease OutbreaksIf a communicable disease outbreak occurs, an understanding of the epidemiology, modes of transmission, and clinical course of the disease is essential for responding to and managing the event. Among the infection control issues that may need to be addressed are:

Preventing transmission among patients, healthcare personnel, and visitors;

Identifying persons who may be infected and exposed; Providing treatment or prophylaxis to large numbers of people; and Logistics issues (staff, medical supplies, resupply, continued operations, and capacity).

Widespread pandemics present special challenges for CAH staffing, supplies, resupply, etc. CAHs should work with local, State, and Federal public health agencies to identify likely communicable disease threats and develop appropriate preparedness and response strategies. Slide17

CAH facilities would confront a set of issues similar to naturally occurring communicable disease threats when dealing with a suspected bioterrorism event. A variety of sources offer guidance for the management of persons exposed to likely agents of bioterrorism, including Federal agency


(e.g., http://www.ahrq.gov/prep; http://www.usamriid.army.mil/ ; http://www.bt.cdc.gov).See Reference page. And check your State agencies.Because of the many similarities between man-made and naturally occurring threats, an all-hazards approach to developing emergency response plans is preferred, and CAHs are encouraged to work with their State and local emergency response agencies to develop their plans. The ICP needs to able to show how their facility manages a communicable disease outbreak as well as a threat of bioterrorism. Please look over the resources that cover this and plan with other department managers.BioterrorismSlide18

The CAH must be prepared to prevent, control and investigate infections and communicable diseases, the CAH’s program must include an active surveillance component that covers both CAH patients and personnel working in the hospital. Surveillance includes infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions.

The CAH must conduct surveillance on a facility-wide basis in order to identify infectious risks or communicable disease problems at any particular location.

This does not imply “total hospital surveillance,” but it does mean that CAHs must have reliable sampling or other mechanisms in place to permit identifying and monitoring infections and communicable diseases occurring throughout the CAH. The CAH must document its surveillance activities, including the measures selected for monitoring, and collection and analysis methods. Surveillance activities must be conducted in accordance with recognized infection control surveillance practices, such as, for example, those utilized by the CDC’s National Healthcare Safety Net (NHSN). Surveillance & Corrective ActionSlide19

Prevention of infections includes the proper maintenance of a sanitary environment. The CAH must

provide and maintain a sanitary environment

to avoid sources and transmission of infections and communicable diseases. All areas of the CAH must be visibly clean and sanitary. This includes all CAH units and off-site locations. The infection prevention and control program must include appropriate monitoring of housekeeping, maintenance (including repair, renovation and construction activities), and other activities to ensure that the CAH maintains a sanitary environment. Examples of areas to monitor would include: food storage, preparation, serving and dish rooms, refrigerators, ice machines, air handlers, autoclave rooms, venting systems, inpatient rooms, treatment areas, labs, waste handling, surgical areas, supply storage, equipment cleaning, etc. Failure to maintain a clean environment would also be a deficiency related to §485.623(b)(4), which requires the CAH to maintain clean and orderly premises.

Sanitary Environment Slide20

The CAH must have policies and procedures in place to mitigate the risks that contribute to healthcare-associated infections. They must incorporate infection control techniques and standard precautions including, but not limited to:


Hygiene Respiratory Hygiene/Cough Etiquette Use of Transmission-Based Precautions such as: contact precautions, droplet precautions, and airborne precautions Use of personal protective equipment (PPE) for healthcare personnel such as gloves, gowns, masks, and respirators Safe work practices to prevent healthcare worker exposure to bloodborne pathogens, such as safety needles and safety engineered sharps devices

Safe medication preparation and administration practices include, but are not limited to: Routine preparation of injectable medications takes place in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed.Mitigation of RiskSlide21

Proper hand hygiene before handling medications; Always disinfect a rubber septum with alcohol prior to piercing it;


using aseptic technique when preparing and administering injections; Never enter a vial with a used syringe or needle; Never administer medications from the same syringe to more than one patient, even if the needle is changed; Recognize that after a syringe or needle has been used to enter or connect to a patient’s IV it is contaminated and must not be used on another patient or to enter a medication vial; Mitigation of Risk-ContinuedSlide22

Never use medications labeled as single-dose or single-use for more than one patient. This includes ampoules, bags, and bottles of intravenous solutions. Exception: It is permissible to use medications that have been repackaged from a previously unopened single-dose container if the repackaging has been done by a pharmacy in a manner consistent with USP/NP Chapter <797> standards, and if the repackaged medications have subsequently been stored consistent with USP <797> and the manufacturer’s package insert, provided that each repackaged dose is used for a single patient.

If multi-dose vials are used for more than one patient, they must not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it must be dedicated to that patient only and discarded after use.

Mitigation of Risk-ContinuedSlide23

Never use bags or bottles of intravenous solution as a common source of supply for more than one patient Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space Never use

insulin pens and other medication cartridges and syringes intended for single-patient-use only for more than one person

Other safe care practices, include, but not limited to: Never use the same fingerstick device for more than one person Avoid sharing blood glucose meters if possible. If they must be shared, the device must be cleaned and disinfected after every use, per manufacturer’s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, it must not be shared.Policies to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another patient Mitigation of Risk-ContinuedSlide24

Policies to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another patient are good to haveThe

CAH must train staff on infection control policies and practices pertinent to the staff’s responsibilities and activities

. For example, the CAH is expected to provide role-specific education on proper hand hygiene, standard and transmission-based precautions, asepsis, sterilization, disinfection, food sanitation, housekeeping, linen care, medical and infectious waste disposal, injection safety, separation of clean from dirty, as well as other means for limiting the spread of infections. Mitigation of Risk-ContinuedSlide25

The CAH is also expected to provide education to patients and their visiting family members/caregivers, when applicable, about precautions to take to prevent infections. The CAH is expected to monitor compliance with all policies, procedures, protocols, and other infection control program requirements and to conduct program evaluation and revision of the program, when indicated.

Mitigation of Risk-ContinuedSlide26

Survey Procedures §485.635(a)(3)(vi) Verify that the CAH has designated a qualified individual to be responsible for the infection control program. Can

the responsible individual demonstrate that the CAH’s program adheres to nationally recognized practices or guidelines?

Is the environment sanitary throughout the CAH? Do CAH staff employ standard precautions appropriately? Do CAH staff employ safe infection control practices for preparing and administering medications? Does the CAH perform active surveillance to identify infections? Can the responsible individual demonstrate how staff compliance with infection control program requirements is assessed and what corrective actions are taken? Can the responsible individual demonstrate that infection control incidents, problems, and trends are analyzed and that corrective actions are taken and further assessed? Is there evidence of training of staff in infection control practices pertinent to their roles? Surveyors List-Qualified IC ProfessionalSlide27

Surveyor Worksheet for Infection Control



Centers for Medicare & Medicaid Services

Hospital Infection Control WorksheetSection 1.A. Infection Prevention Program and Resources1.A.1: The hospital has designated one or more individual(s) as its Infection Control Officer(s).  

  1.A.2: The Hospital has evidence that demonstrates the Infection Control Officer(s) is qualified and maintain(s) qualifications through education, training or certification related to infection control consistent with hospital policy. Proposed CAH CoPs: An individual who are qualified through education, training, experience, or certification in infection prevention and control, are appointed by the governing body, or responsible individual, as the Infection Preventionist / infection control professional responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership.


  1.A.3: The Infection Control Officer(s) can provide evidence that the hospital has developed general infection control policies and procedures that are based on nationally recognized guidelines and applicable state law.

 Proposed CAH CoPs: The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings.  


1.A.4: The Infection Control Officer can provide an updated list of diseases reportable to the local and/or state public health authorities.   


1.A.5: The Infection Control Officer can provide evidence that hospital complies with the reportable diseases requirements of the local health authority.





HandwashingProper use of disinfecting agentsSurgery-sterilizations processes/procedures, instrument cleaning, temperature an humidity, air exchanges, traffic, handling of specimens.


Antibiotic StewardshipAntibiotic resistance is now a major issue confronting healthcare providers and their patients. Changing antibiotic resistance patterns, rising antibiotic costs and the introduction of new antibiotics have made selecting optimal antibiotic regimens more difficult now than ever before. Furthermore, history has taught us that if we do not use antibiotics carefully, they will lose their efficacy. As a response to these challenges, **Any topic that is an area of needed improvement found through your IC Risk Assessment, how you developed specific targets and what actions have been taken to address each issue.Surveyor Hot Topics Slide29

Risk Assessment

Annual Goals

Strategies to Reduce Infection Risk Evaluation of Plan EffectivenessResources for YouInfection Control Annual Risk Assessment and GoalsSlide30

Infection Control Goals based on Risk Assessment Example

Goal: Reduce risk of healthcare-associated infections for all patients, employees and visitors

Target 1: Reduce catheter-associated urinary tract infections house wide by 10% below FY 2016 rate

Action ItemsWhatWhoWhen

MetricImplement automatic discontinue orders for catheters based on criteria approved by the medical staffDevelop protocol based on evidence-based dataSubmit protocol to Nursing Congress and Medical Staff for review and approvalEducate medical staff and nursing staffInclude as part of new orientation for all nursing staffAudit for compliance with protocolIC NurseNursing LeadersMEC1. 1/16

2. 2/163. 3/164. 4/165. 4/1695% compliance with protocol within 60 days of implementationSlide34

Thank you.Slide35

Agency for Healthcare Research and Quality. (2017, Jan. 19). Public health emergency preparedness. Retrieved from


www.ahrq.gov/prepAssociation for Professionals in Infection Control and Epidemiology. (2017, Jan. 19). Resources. Retrieved from apic.org/resourcesCenters for disease control and prevention. (2017, Jan. 20). Bioterrorism. Retrieved from http://www.bt.cdc.govCenters for disease control and prevention. (2017, Jan. 19). Menu of definitions. Retrieved from http://www.cdc.gov/tb/programs/laws/menu/definitions.htmFederal Register. Antimicrobial stewardship. (2017, Jan. 25). Retrieved from http://www.apic.org/Resources/Topic-specific-infection-prevention/Antimicrobial-stewardshipFederal Register. (2017, Jan. 19). Retrieved from https://www.federalregister.gov/

National Institute for Allergies and Infectious Diseases. (2017, Jan. 19). Resources. Retrieved from http://www.niaid.nih.gov/topics/microbes/pages/glossary.aspxUnited States Army Medical Department. (2017, Jan. 20). US Army medical research institute of infectious diseases. Retrieved from http://www.usamriid.army.mil/ ReferencesSlide36


Hosted by: HealthTechS3 Consultants

Registration Link: https://attendee.gotowebinar.com/register/1267422825715419139TOOLS AND RESOURCES FOR SUCCESSFUL ADVANCED CARE PLANNINGThursday, February 16, 201712:00 PM - 1:00 PMHosted by: Faith M Jones, MSN, RN, NEA-BCDirector of Care Coordination and Lean ConsultingRegistration Link: https://attendee.gotowebinar.com/register/3223625535343402243CREATING AN ENGAGED WORKFORCE IN CHANGING TIMESFriday, February 17, 201712:00 PM - 1:00 PM CSTHosted by: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCARegional Chief Clinical OfficerRegistration Link: https://attendee.gotowebinar.com/register/3274735233849000707

PHYSICIAN ENGAGEMENT STRATEGIES FOR RURAL HOSPITALSThursday, February 23, 201712:00 PM - 1:00 PM CSTHosted by: Michael LiebRegional Vice President & Director, Practice ManagementRegistration Link: https://attendee.gotowebinar.com/register/1549561907449283331COPS FOR CRITICAL ACCESS HOSPITALS: WHAT’S NEW AND WHAT YOU NEED TO KNOWFriday, March 3, 201712:00 PM - 1:00 PM CSTHosted by: Carolyn St.Charles, RN, BNS, MBARegional Chief Clinical OfficerRegistration Link: https://attendee.gotowebinar.com/register/1947597211332234499Slide37

If you have questions or would like a review of your Infection Control programPlease contact me


St.Charles Regional Chief Clinical Officercarolyn.stcharles@healthtechS3.com360-584-986837