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 - Implemented by November 2016
    • Infection Control Program
    • Linens
    • Flu and Pneumonia Vaccines (reorganized under Infection Control)
  2. Phase 2 - Implemented by November 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:


  • 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

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


Infection and Antibiotic Tracking

Being mindful that many facilities have individuals with multiple responsibilities (i.e. both infections and antibiotic use), a MONTHLY INFECTION AND ANTIBIOTIC TRACKING FORM has been developed to streamline the tracking, analysis and monitoring of these two major areas of importance.

This monthly tracking form provides an organized tool to maintain "real-time" information for both infections and antibiotic utilization. The tracking form itself is in an Excel format for universal use. All data entry is completed and maintained on one tab/sheet within the file. All data is instantaneously summarized, analyzed and graphed for not only the entire facility, but also for up to 10 “user-defined” units or locations.

The initial set-up of the tracking form allows for the entry of up to 25 different prescribers on a separate tab/sheet that instantly flows to the prescriber "dropdown" choices on the data entry sheet.

This prescriber assignment allows the tracking form to offer “prescriber-specific” antibiotic use summaries and graphs that may be printed for separate review and conversation with the appropriate parties.

The tracking sheet also calculates appropriate rates based on resident days. There is an option to provide "location-specific" resident days to have the tracking form also calculate both infection and antibiotic use rates for each "user-defined" location.

Webex "IPRO Infection and Antibiotic Tracking Tool"

  • WMV Format: this version will be downloaded to your computer

To request this tracking forms, simply contact
It would be helpful if you would provide your facility name and location along with specific tool you are requesting

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

Maureen Valvo, RN, BSN, RAC-CT
Senior Quality Improvement Specialist
Tel: (516) 209-5308

David L. Johnson, NHA, RAC-CT
Senior Quality Improvement Specialist
Tel: (518) 320-3516

Dan Yuricic, MA
Senior Quality Improvement Specialist
Tel: (516) 209-5458

IPRO Nursing Home Team


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