This week’s “Ftag of the Week” is F880 Infection Prevention & Control, which we will be looking at over the course of the next couple of posts on the CMSCG Blog since this is such an important regulation to understand. Why? Infection Prevention and Control is the most frequently cited deficient practice in the country currently and is always one of the most frequently cited deficiencies year after year. The Centers for Medicare & Medicaid Services (CMS) has made it clear that they are looking for a thorough and comprehensive program that both prevents and controls infections in the facility.
The regulation at F880 requires that nursing facilities establish and maintain “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” CMS has really placed a focus on the proactive, preventative part of the program in the RoPs, including with the requirement for an Infection Preventionist in Phase 3 (F883 Infection Preventionist will be an Ftag of the Week shortly – stay tuned).
The requirements for the Infection Prevention and Control Program (IPCP) include:
- A system for prevention, identification, reporting, investigation and control of infections and communicable diseases. The system must be able to do this for all residents, staff (including those providing services via contract), visitors and volunteers in the facility as well and should be based on the Facility Assessment and follow nationally accepted standards.
- The IPCP must include written standards, policies and procedures for elements of the program including surveillance, reporting potential incidents, standard and transmission-based precautions, isolation, prohibition of employees from direct contact with residents or their food under certain circumstances and hand hygiene. Many of these areas are what are frequently cited on survey since facility staff often fail to follow procedures appropriately, indicating a need for additional focus in these areas through competencies and training.
- A system for recording incidents identified under the IPCP and corrective actions taken by the facility. Deficient practices have been identified in this area when facilities have not completed line listings or tracked GI breakouts in facilities.
- The IPCP must also address how staff handle/store/process and transport linens.
The Infection Prevention and Control Program must be reviewed and updated annually and as needed. It’s a good idea to ensure that the IPCP still aligns with the Facility Assessment (also required to be updated annually) to ensure that the IPCP is comprehensive and facility-specific. The results of the Facility Assessment, per the IG, require that they are used (at least partially) to establish and update the IPCP. Since the Facility Assessment must include both an all-hazards facility-based assessment as well as an all-hazards community-based assessment, the results of a risk review for infections and communicable diseases will help the facility develop its IPCP. CMS states that there is a sample infection control risk assessment tool available that can be adapted for use but use of this tool is not required for compliance. That tool is the APIC “IC risk assessment tool form and IC risk assessment analysis.” Those and other resources can be found on this APIC webpage.
Stay tuned for more on the Infection Prevention and Control Requirements under the Requirements of Participation on the CMSCG Blog.