Nursing Home Quality Care Collaborative Learning Series

Working to improve the quality of care delivery to nursing home residents.

Reform of Requirements for Long-Term Care Facilities

483.80 Infection Control

  1. Phase 1 - Implementation by 11/28/2016
    • Infection Control Program
    • Linens
    • Flu and Pneumonia Vaccines (reorganized under Infection Control)
  2. Phase 2 - Implementation by 11/28/2017
    Antibiotic Stewardship
  3. Phase 3 - Implementation by 11/28/2019
    Infection Preventionist with Specialized Training

Infection Prevention and Control Program:

A system for preventing, identifying, reporting, investigating, and controlling infection and communicable diseases for all residents, staff volunteers, visitors, and other individuals providing services under a contractual arrangements based upon the facility assessment and following accepted national standards. Written standards, policies, and procedures for the program, must include, but are not limited to the following components:

Component

  • A system of surveillance designed to identify possible communicable diseases or infections before they can spread to others in the facility
  • When and to whom possible incidents of communicable disease or infections should be reported
  • Standard and transmission-based precautions to be followed to prevent spread of infections
  • When and how isolation should be used for a resident, including but not limited to:
    • The type and duration of the isolation, depending upon the infectious agent or organism involved.
    • A requirement that the isolation should be the least restrictive possible for the resident.
    • The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with resident or their food
    • The hand hygiene procedures to be followed by staff involved in direct resident contact.
  • A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility.
  • An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use (November 2017).

Infection Preventionist

The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility’s IPCP (November 2019).

The IP must:

  • Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field.
  • Be qualified by education, training, experience or certification.
  • Work at least part-time at the facility.
  • Have completed specialized training in infection prevention and control
  • Participate on quality assessment and assurance committee.
    The individual designated as the IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Influenza Immunizations

The facility must develop policies and procedures to ensure that:

  • Before offering the influenza immunization, each resident or the resident representative receives education regarding the benefits and potential side effects of the immunization
  • Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period
  • The resident or the resident’s representative has the opportunity to refuse immunization
  • The resident’s medical record includes documentation that indicates, at a minimum:
  • That the resident or resident’s representative was provided education regarding the benefits and potential side effect of influenza immunization.
  • That the resident either received the influenza immunization or did not receive the immunization due to medical contraindications or refusal

Linens
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection
Annual Review
The facility will conduct an annual review of its IPCP program and update their program as necessary

Resources

Influenza Immunizations

Pneumococcal Disease

Contact Us

New York

Pauline Kinney, RN, MA, LNHA, RAC-CT
Senior Director, Health Care Quality Improvement
Tel: (516) 209-5402
Fax: (516) 326-0434
pauline.kinney@area-I.hcqis.org

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308
Maureen.valvo@area-I.hcqis.org

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516
David.johnson@area-I.hcqis.org

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458
Danny.yuricic@area-I.hcqis.org

IPRO Nursing Home Team
ipronursinghometeam@ipro.org

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