New Programs and Required Reporting for Long Term Care (LTC)
|
|
- Joleen Henry
- 6 years ago
- Views:
Transcription
1 New Programs and Required Reporting for Long Term Care (LTC) New Centers for Medicare and Medicaid Services (CMS) Requirements Slide: D. Burdsall 1
2 The mission of the U.S. Centers for Medicare & Medicaid Services (CMS) is to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries. CMS Statement on LTC Situation Healthcare associated infections (HAIs) are largely preventable and occur too often in nursing homes Multiple factors Understaffed facilities Staff without the appropriate training or time to prevent infections early Overtreatment with antibiotics Increasing clinical complexity of the average nursing home resident Frequent transitions between care settings that lead to the transmission of HAIs Lack of a systematic approach to prevent and identify HAIs Source: CMS Survey and Certification Group 2016/2017 Nursing Home Action Plan Personal Cost of HAIs Between 1.6 and 3.8 million HAIs in nursing homes every year Science Photo Infections result in an estimated 150,000 hospitalizations, 388,000 deaths Strausbaugh, L., & Joseph, C. (2000). The Burden of Infection in Long-Term Care. Infection Control & Hospital Epidemiology, 21(10), doi: / Slide: D. Burdsall 2
3 CMS Infection Prevention and Control Program (IPCP) Reform of Requirements Phase I Phase II November 28, 2016 November 28, 2017 Phase III Basis and Scope Definitions Basic IPCP QAA Committee IPCP linked to Facility Assessment Antibiotic stewardship QAPI plan available for surveyors November 28, 2019 Infection preventionist (IP) IP participation on QAA committee (QAPI) Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. Slide: D Burdsall 7 Illinois SNF Requirements: 2012 Designate Infection Prevention and Control Professional(s) Develop and implement policies governing control of infections and communicable diseases Qualified through education, training, experience or certification (or a combination) Qualifications shall be documented and made available for inspection (Source: P.A , eff , Section 99. Effective date. January1, ) Phase II Requirements November 28, 2017 Infection Prevention and Control Program linked to the Facility-wide Assessment Antibiotic Stewardship Program Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. Slide: D Burdsall 9 3
4 Facility-wide Assessment Determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies The facility must review and update that assessment: As necessary At least annually Whenever there is, or facility plans for, any change that would require a substantial modification to any part of this assessment Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. Image: Pixabay_P. Marco Slide: D Burdsall 10 Must Address: Residents, Patients and Clients The facility s resident population, including, but not limited to: Number of residents Facility s resident capacity The care required by the resident population: Types of diseases, conditions, physical and cognitive disabilities Overall acuity Other pertinent facts that are present within that population Any ethnic, cultural, or religious factors that may potentially affect the care provided: Activities Food Nutrition Pixabay Slide: D Burdsall 11 Must Address: Personnel Necessary staff competencies for level and types of care needed Any ethnic, cultural or religious factors that may potentially affect the care All personnel, including managers, staff (both employees, volunteers, and those who provide services under contract) Slide: D Burdsall 12 4
5 Must Address: Education SciencePhoto Goal: staff comply with infection control practices Initial and ongoing infection control education Updated education and training when policies and procedures are revised when there is a special circumstance (e.g., outbreak) requires modification or replacement of current practices Slide: D Burdsall 13 Must Address: Training and Competency Task and discipline specific infection control training insertion of urinary catheters suctioning intravenous care Stock Unlimited blood glucose monitoring Follow-up competency evaluations identify staff compliance Slide: D Burdsall 14 M. Makien Antimicrobial Stewardship Require antibiotic stewardship program, antibiotic use protocols, and a system for monitoring antibiotic use The Core Elements of Antibiotic Stewardship for Nursing Homes Slide: D Burdsall 15 5
6 Major Changes Photos: SciencePhoto Antimicrobial Stewardship including antibiotic use protocols system to monitor antibiotic use Coordinate and participate in QAPI Slide: D Burdsall 16 Why focus on antimicrobial stewardship in nursing homes? Residents and patients frequently colonized with multi drugresistant organisms (MDRO) 30%-50% of frail, elderly long-term care residents with asymptomatic bacteriuria LTCF reservoir for MDRO Poor communication Pixabay Antibiotic-related complications, (e.g., C. difficile infection), more severe, difficult to treat, lead to more hospitalizations and deaths among people over 65 years Source: CDC: Slide: D Burdsall 17 Antibiotics are among the most frequently prescribed medications in nursing homes Source: CDC: prevention/antibioticstewardship.html Slide: D Burdsall 18 6
7 Challenges to Antibiotic Stewardship Approximately 20% of healthcare prescribers account for approximately 80% of prescribed antibiotics 40-75% of antibiotics are inappropriately prescribed Almost 50% of antibiotics are given longer than necessary Source: CDC: Daneman, N et.al. Prolonged Antibiotic Treatment in Long-term Care. JAMA Intern Med. 2013; E1-E Slide: D Burdsall 19 Source: CDC: Infection Control Assessment Tools: Slide: D Burdsall 20 CDC Steps to Get Smart about Antibiotic Prescribing Obtain cultures before starting antibiotics when possible Adjust or stop antibiotics when appropriate Use antibiotics to treat bacterial infections only, not viral illnesses Use antibiotics only for as long as needed Antibiotics are generally not indicated to treat colonization Engage residents and their family members to improve antibiotic use Source: CDC: Antibiotic Use in Nursing Homes Slide: D Burdsall 7
8 Required Reporting in Long Term Care Slide: D. Burdsall Reporting and the Qualified Infection Preventionist (IP) Work with local and state health departments Report and control outbreaks Goal is rapid control of disease Outbreaks have traditionally been under-reported 23 Illinois Department of Public Health (IDPH) The mission of IDPH is to promote health through the prevention and control of disease and injury. IDPH assures the quality of our food, sets standards for hospitals and nursing homes, investigates disease outbreaks, maintains the state s vital records, screens newborns, and many other programs. 8
9 Illinois Department of Public Health (IDPH) About 1,200 long-term care facilities serving more than 100,000 residents Licensed, regulated and inspected by the Illinois Department of Public Health (IDPH) IDPH assists the U.S. Centers for Medicare and Medicaid Services (CMS) Certifying facilities for participation in federal payment reimbursement programs Reporting outbreaks is an important but frequently overlooked responsibility in LTC Reporting and Precautions in a Social Model Biopsychosocial Model of Care Epidemic or Outbreak Situation Slide: Burdsall, D 9
10 Required Reporting Your local health department TB district Potentially State Health Department Regulatory Health Care Facility Definition Ambulatory surgical treatment centers Home health agencies and hospices Hospitals End-stage renal disease facilities Long-term care facilities Medical assistance facilities Mental health centers Outpatient facilities Public health centers Rehabilitation facilities Residential treatment facilities Adult day care centers Source: Title 77 PART 690 CONTROL OF COMMUNICABLE DISEASES CODE Is there anyone who DOESN T need to report? Physicians, Physician assistants, Nurses, Nursing assistants, Dentists, Health care practitioners, Emergency medical services personnel, Laboratory personnel, Long-term care personnel, Any institution, school, college/university, child care facility or camp personnel Pharmacists, Poison control center personnel, Blood bank and organ transplant personnel, Coroners, funeral directors, morticians and embalmers Medical examiners, Veterinarians, Correctional facility personnel, Food service management personnel Any other person having knowledge of a known or suspected case or carrier of a reportable communicable disease or communicable disease death The master, pilot or any other person in charge of any bus, train, ship or boat, and the commander, pilot or any other person in charge of any aircraft within the jurisdiction of the State Researchers Source: Illinois Title 77 Part 690 Communicable Disease Code 10
11 Define What to Report Cluster Two or more persons with a similar illness, usually associated by place or time Communicable Disease An illness due to a specific infectious agent or its toxic products that arises through transmission Outbreak The occurrence of illness Epidemiologically associated Rate in excess of normal Number of cases disease specific General Outbreak Definition IDPH Outbreak The occurrence of illness in a person or a group of epidemiologically associated persons, with the rate of frequency clearly in excess of normal expectations. The number of cases indicating presence of an outbreak is disease specific. More Specific Outbreak Reporting Definition IDPH Any pattern of cases, or increased incidence of any illness beyond the expected number of cases in a given period, that may indicate an outbreak, including suspect or confirmed outbreaks of foodborne or waterborne disease, or outbreaks transmitted by laboratory acquisition, animal contact, person-to-person contact, inhalation or other transmission method, shall be reported to the local health authority within 24 hours. This includes, but is not limited to, outbreaks of gastroenteritis and group A streptococcal disease (including invasive infections, necrotizing fasciitis, and toxic shock syndrome). 11
12 Outbreak Reporting Expectations Two (2) or more cases of a suspected or reportable infectious disease Cooperate with public health authorities Investigate cases, suspect cases, outbreaks and suspect outbreaks Release of food preparation methods and menus Customers, attendees, residents or patients (people) diagnosed Environmental, food, and clinical specimens Long Term Care Regulatory All illnesses required to be reported under the Control of Communicable Diseases Code and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693) Report immediately to the local health department and to the Department. Facility shall furnish all pertinent information relating to such occurrences In addition, the facility shall inform the Department of all incidents of scabies and other skin infestations. Skilled, Intermediate, Sheltered, Assisted Living and Shared Housing Nursing Facilities Source: Title 77 Subchapter c Long Term Care Facilities Reporting in Illinois Reportable diseases and conditions Extensively drug resistant organisms (XDRO) Active Tuberculosis Disease Outbreaks/clusters Gastroenteritis Influenza and influenza-like illness Scabies and other skin infestations* 12
13 Who is Included in LTC Reporting? Assisted Living and Shared Housing* Community Living Facilities Illinois Veterans Homes* Intermediate Care Facilities for the Developmentally Disabled* Skilled Nursing and Intermediate Care* Long Term Care for Under Age 22 Shared Housing Sheltered Care Facilities* Skilled Nursing Facilities Supportive Residences* Supportive Residents Specialized Mental Health Rehabilitation * Scabies and other skin infestations reportable
14 -and-report-poster.pdf "Extensively Drug- Resistant Organisms" or "XDRO" A pathogen that is difficult to treat because it is non-susceptible to all or nearly all antibiotics XDRO Registry Effective November 1, 2013 Report first CRE-positive culture per patient stay The following health care facilities are required to report patient XDRO incident information: Hospitals Long-term acute care hospitals LTACH Hospital-affiliated clinical laboratories Independent or free-standing laboratories Long-term care facilities Source: Added at 37 Ill. Reg , effective July 15,
15 Purpose of the XDRO registry Improve CRE surveillance First CRE-positive culture per patient stay must be reported to the XDRO registry Improve inter-facility communication Healthcare facilities can query the XDRO registry to see whether a patient has been previously reported as CRE-positive January 2017, IDPH entering Candida auris cases into the XDRO registry. April 2017, IDPH entering carbapenemase-producing Pseudomonas aeruginosa cases into the XDRO registry. Source: XDRO registry overview Participants: All Illinois acute care and long-term acute care hospitals (~200), skilled nursing facilities (~800), laboratories Slide: IDPH and the CDC Chicago Prevention and Intervention Epicenter Created August
16 How to obtain XDRO registry access Apply for access at: Slide: IDPH and the CDC Chicago Prevention and Intervention Epicenter Created August 2016 Illinois National Electronic Disease Surveillance System (I-NEDSS) A secure, web-based application available to health care providers and other reporters Input demographic, medical and exposure information on patients diagnosed with reportable conditions Once a report is entered, it is immediately routed to the appropriate local health department for additional follow-up No Access to I-NEDSS? Report by mail, telephone or fax to the local health department No local health department? Report to the Illinois Department of Public Health Division of Infectious Diseases at TTY (hearing impaired use only)
17 Sample Single Shot Case Studies 10 FOR COMPARISON No Bundle Norovirus Confirmed Gastrointestinal Outbreak 101 Cases Residents and Staff Attack Rate= 29% 34 days duration /4/11 12/11/11 12/18/11 12/25/11 1/1/12 1/8/12 1/15/12 1/22/12 1/29/12 D. Burdsall 50 Outbreak Control with Bundle and Health Department Guidance 17
18 Acute Gastroenteritis on a Dementia Unit January Cases: 3 Confirmed Norovirus Attack Rate: Residents and Staff 6.6% 8 days duration Reported, Lab Sample Sent, and Bundle Started Confirmed Norovirus Lab Result Received AFTER Outbreak Controlled SX Case Def D. Burdsall 52 Contact/Droplet Precautions Source: E. Nelson, Lutheran Life Communities D. Burdsall 53 IDPH Confirmed Influenza Outbreak LTC Influenza like illness (ILI): Fever (a temperature of 100⁰ F [37.8⁰ C] or higher orally) AND new onset cough or sore throat Two or more cases of ILI occurring within 72 hours among residents in a unit of the facility with at least one of the ill residents having laboratory-confirmed influenza 18
19 Influenza B and RSV Mixed Respiratory Illness March Influenza B, 1 RSV, and 12 unknown 20 cases Attack Rate 10% Duration 9 days Started Bundled Approach Influenza B Pos RSV Other Reported D. Burdsall 55 How Many Cases of Influenza do You Need to Consider it an Outbreak? Scenario: Two residents on one unit are complaining of chills, aching, fever, coughing and congestion. One resident states she wants dinner in her room because she is coming down with a cold One resident swabs positive for influenza Is this an outbreak? If the facility is not doing active surveillance, how would you know? 19
20 Infection Prevention and Control is a Human issue, and needs to be dealt with within a biopsychosocial and spiritual framework Spiritual Social HUMAN Psychological Biological Slide: D Burdsall 20
Part II Quality improvement in long-term care: Partnership of infection prevention and environmental services
Part II Quality improvement in long-term care: Partnership of infection prevention and environmental services Using the Centers for Medicare and Medicaid Services (CMS) Quality Assurance Performance Improvement
More information2/23/2017. Preparing to Meet New Infection Prevention Requirements in Skilled Nursing Facilities. Objectives
Preparing to Meet New Infection Prevention Requirements in Skilled Nursing Facilities Aimee Ford, Qualis Health Patricia Montgomery, WA State Department of Health Washington Health Care Association Winter
More informationAntibiotics - Are they OVERUSED? 4/6/2018. Antibiotic Stewardship Key Clinical Strategies for Successful Outcomes. Pathway Health 1.
Antibiotic Stewardship Key Clinical Strategies for Successful Outcomes Louann Lawson, BA, RN, RAC-CT, CIMT Nurse Consultant Clinical Reimbursement Team Leader/Clinical Education Manager Pathway Health
More informationIntroduction to Infection Prevention and Control (IPC) Open Call Series #1 Surveillance
Introduction to Infection Prevention and Control (IPC) Open Call Series #1 Surveillance Diane Dohm MT, IP, CIC, CPHQ MetaStar February 6, 2018 IPC Open calls: Bi-weekly Series Surveillance What data should
More informationThe Core Elements of Antibiotic Stewardship with CMS and QAPI Updates
The Core Elements of Antibiotic Stewardship with CMS and QAPI Updates Emily Lutterloh, MD, MPH Director, Bureau of Healthcare Associated Infections New York State Department of Health February 8, 2017
More informationInfection Prevention and Control and Antibiotic Stewardship: More than Counting Beans
Infection Prevention and Control and Antibiotic Stewardship: More than Counting Beans Teresa Fox, CIC Quality Improvement Advisor teresa.fox@area-g.hcqis.org Welcome Beth Greene, Quality Improvement Advisor
More informationQAPI & Infection Prevention: Putting the Pieces Together
QAPI & Infection Prevention: Putting the Pieces Together Tammy Baumann, RN, LSSGB Quality Improvement Advisor Great Plains Quality Innovation Network Objectives Identify how QAPI intersects with infection
More informationState of the State Address on HAI Prevention Activities
State of the State Address on HAI Prevention Activities Disclaimer/Conflict of Interest I have no disclaimers or conflicts of interest to report Objectives Identify priority action areas and components
More informationHow to Add an Annual Facility Survey
Add an Annual Facility Survey https://nhsn.cdc.gov/nhsndemo/help/patient_safety_component/how_to/add_an_annual... Page 1 of 1 10/9/2017 Show Patient Safety Component > How To > Facility > Add an Annual
More informationAntimicrobial Stewardship Program in the Nursing Home
Antimicrobial Stewardship Program in the Nursing Home CAHF San Bernardino/Riverside Chapter May 19 th, 2016 Presented by Robert Jackson, Pharm.D. Pharmaceutical Consultant II, Specialist CDPH Licensing
More information11/3/2017. Infection Control Assessment and Response (ICAR) Tools. Infection Control Assessment and Response (ICAR) Tools
Infection Control Assessment and Response (ICAR) Tools Fresh Eyes Collaborative Approach Infection Control Assessment and Response (ICAR) Tools Comprehensive documents/questionnaires identify elements
More informationInfection Control Assessment and Response (ICAR) Tools. Fresh Eyes Collaborative Approach
Infection Control Assessment and Response (ICAR) Tools Fresh Eyes Collaborative Approach Infection Control Assessment and Response (ICAR) Tools Comprehensive documents/questionnaires identify elements
More informationNursing Home Online Training Sessions Session 4: Antibiotic Stewardship
National Nursing Home Quality Care Collaborative Nursing Home Online Training Sessions Session 4: Antibiotic Stewardship Health Services Advisory Group (HSAG) Objectives 1 Welcome and overview. 2 Define
More informationInvestigating Clostridium difficile Infections
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH Investigating Clostridium difficile Infections Erin P. Garcia, MPH, CPH Healthcare-Associated Infections (HAI) Program Center for Health Care Quality California Department
More informationInfection Prevention. Fundamentals of. March 21-23, 2017 Oregon Medical Association Portland, OR. oregonpatientsafety.org
Fundamentals of Infection Prevention A Comprehensive Training Course for Infection Prevention Professionals March 21-23, 2017 Oregon Medical Association Portland, OR oregonpatientsafety.org Course Information
More informationInfection Prevention, Control & Immunizations
Infection Control: This facility task must be used to investigate compliance at F880, F881, and F883. For the purpose of this task, staff includes employees, consultants, contractors, volunteers, and others
More informationInfection Prevention and Control Program
Infection Prevention and Control Program UNDERSTANDING AND MANAGING THE REGULATORY CHANGES IN YOUR PROGRAM Melissa J. Mitchell, R.N., B.S.N F Tag 880 According to F Tag 880 the Infection Prevention and
More information2017 State of the State Address on Prevention of Health Care Associated Infections and Antimicrobial Resistance
2017 State of the State Address on Prevention of Health Care Associated Infections and Antimicrobial Resistance Erica Runningdeer, MSN, MPH, RN HAI Prevention Coordinator Division of Patient Safety & Quality
More informationDEVELOPMENT OF AN INFECTION CONTROL PROGRAM FOR LONG-TERM CARE FACILITIES. Evelyn Cook, RN, CIC Associate Director
DEVELOPMENT OF AN INFECTION CONTROL PROGRAM FOR LONG-TERM CARE FACILITIES Evelyn Cook, RN, CIC Associate Director Understanding Long-Term Care Varying terms and degrees of inclusiveness Difficult to have
More informationObjectives. Industry Landscape. Infection Prevention and Control Changes, Updates and Quality Results!
Infection Prevention and Control Changes, Updates and Quality Results! Sue LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT Director of Education Pathway Health 1 Objectives 1.Describe the recent industry
More informationLightning Overview: Infection Control
Lightning Overview: Infection Control Gary Preston, PhD, CIC, FSHEA Terry Caton, CIC Carla Ward, CIC 2012 Healthcare Management Alternatives, Inc. Objectives At the end of this module you will know: How
More informationCore Elements of Antibiotic Stewardship for Nursing Homes
Core Elements of Antibiotic Stewardship for Nursing Homes Welcome! Holly Harmon, RN, MBA, LNHA Senior Director Clinical Services 1 Leonard Russ Immediate Past Chair AHCA Board of Governors Antibiotic Stewardship
More informationAntimicrobial Stewardship and the New Regulations
Antimicrobial Stewardship and the New Regulations Robin Trotman, DO, FIDSA CoxHealth Infectious Diseases Specialty Clinic March 3, 2017 Outline: Introduction to new CMS regulations Rationale for these
More informationBEHAVIORAL HEALTH & LTC. Mary Ann Kellar, RN, MA, CHES, IC March 2011
BEHAVIORAL HEALTH & LTC Mary Ann Kellar, RN, MA, CHES, IC March 2011 CDC Isolation Guidelines-adapting to special environments MDRO s CMS-F 441 C.difficile Norovirus Federal (CMS), State & Joint Commission
More informationInfection Prevention and Control Training
National Center for Emerging and Zoonotic Infectious Diseases Infection Prevention and Control Training Abimbola (Bola) Ogundimu, DrPH, RN, CIC Infection Preventionist for LTC CDC Division of Healthcare
More informationInfection Prevention and Control: How to Meet the Conditions of Participation for Home Health
Infection Prevention and Control: How to Meet the Conditions of Participation for Home Health Mary McGoldrick, MS, RN, CRNI Home Care and Hospice Consultant Saint Simons Island, GA Nothing to Disclose
More informationUpcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know
Upcoming Changes in Infection Prevention: What Skilled Nursing Facilities Need to Know Aimee Ford, QI Consultant, Qualis Health June 8, 2016 Qualis Health A leading national population health management
More informationWelcome and Introduction
Welcome and Introduction 1 Webinar Speakers Lynn Tabor, MS, RN, WCC, IP-BC, ASCOM Director of Education and Training, American Medical Technologies Jan Ruhl, BSN, RN, IPCO Golden Age Nursing Home, Guthrie
More informationInfectious Diseases-HAI, Infectious Diseases Connecticut Department of Public Health, Infectious Disease: Healthcare Associated Infections, STD/TB
Infectious Diseases-HAI, Infectious Diseases Connecticut Department of Public Health, Infectious Disease: Healthcare Associated Infections, STD/TB Hartford, Connecticut Assignment Description The Fellowship
More informationAntibiotic Use and Resistance in Nursing Homes
Antibiotic Use and Resistance in Nursing Homes GHINWA DUMYATI, MD PROFESSOR OF MEDICINE CENTER FOR COMMUNITY HEALTH UNIVERSITY OF ROCHESTER MEDICAL CENTER FEBRUARY 8, 2017 Nicolle LE, et al. Antimicrobial
More informationInfectious Diseases- HAI Tennessee Department of Health, Healthcare Associated Infections and Antimicrobial Resistance Program/ CEDEP
Infectious Diseases- HAI Tennessee Department of Health, Healthcare Associated Infections and Antimicrobial Resistance Program/ CEDEP Nashville, Tennessee Assignment Description The Fellow will be located
More informationMHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative
MHA/OHA HIIN Antibiotic Stewardship/MDRO Collaborative Place picture here Sept. 12, 2017 Reminders For best sound quality, dial in at 1-800-791-2345 and enter code 11076 Please use the chat box to ask
More informationApic Infection Control Manual For Long Term Care Facilities
Apic Infection Control Manual For Long Term Care Facilities Overview Monthly alerts for consumers Materials for healthcare facilities Additional Film festival uses humor and education to promote infection
More informationInfection Control. Regulatory Changes and Interpretive Guidance Surveyor Training
Infection Control Regulatory Changes and Interpretive Guidance Surveyor Training 1 F Tags Regulatory Group: Infection Control F880: Infection Prevention and Control ( Old F441 ) 483.80 (a)(1-2)(4)(e-f)
More informationFederal Requirements of Participation for Nursing Homes Summary of Key Changes in the Final Rule Issued September 2016 Phase 2
Federal Requirements of Participation for Nursing Homes Summary of Key Changes in the Final Rule Issued September 2016 Phase 2 On September 28, 2016, the Centers for Medicare & Medicaid Services (CMS)
More informationMedication Related Changes Phase 1&2
Medication Related Changes Phase 1&2 Medicare and Medicaid Programs Reform of Requirements for Long-Term Care Facilities Published January 23, 2017 Medication- Related Changes* Changes will be implemented
More informationRisk Assessment. Developing an Infection Prevention plan
Risk Assessment Developing an Infection Prevention plan Success Depends on Preparation and Planning OBJECTIVES: Identify at risk services, populations, and procedures at your hospital Construct an IC Risk
More informationAugust 22, Dear Sir or Madam:
August 22, 2012 Office of Disease Prevention and Health Promotion 1101 Wootton Parkway Suite LL100 Rockville, MD 20852 Attention: Draft Phase 3 Long-Term Care Facilities Module Dear Sir or Madam: The Society
More informationWEBINAR: Making the Numbers Count-Using Your Pharmacy Data to Support Antibiotic Stewardship and Infection Control
WEBINAR: Making the Numbers Count-Using Your Pharmacy Data to Support Antibiotic Stewardship and Infection Control New England Nursing Home Quality Care Collaborative Webinar Will Begin Shortly. Call-In
More informationAntibiotic Stewardship Program (ASP)
Introduction: Antibiotics are among the most frequently prescribed medications in nursing centers, with up to 70% of nursing home patients receiving one or more courses of systemic antibiotics in a year.
More informationAPPLICATION. Thank you for your interest in applying for the APIC Program of Distinction.
APPLICATION Thank you for your interest in applying for the APIC Program of Distinction. This application has three parts: u PART 1: u PART 2: Personnel Information u PART 3: Required Documents Facilities
More informationObjectives. IPC Open calls - bi-weekly series. Introduction to Infection Prevention & Control (IPC) Open Call Series
Introduction to Infection Prevention & Control (IPC) Open Call Series #4 Transmission Precautions Isolate the Organism and Not the Resident Diane Dohm MT, IP, CIC, CPHQ MetaStar Anne Haddad, MPH MPRO March
More informationClinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness Version 2
GUIDANCE AND RECOMMENDATIONS Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness Version 2 This document provides
More informationTag Description Page. F607 Policies to Prohibit and Prevent Abuse, Neglect, Exploitation 125. F622 Transfer & Discharge 155
Tag Description Page F607 Policies to Prohibit and Prevent Abuse, Neglect, Exploitation 125 F622 Transfer & Discharge 155 F626 Permitting Residents to Return to Facility 170 F656 Comprehensive Care Plans
More informationTRANSMISSION-BASED PRECAUTIONS
TRANSMISSION-BASED PRECAUTIONS PRECAUTIONS Standard Precautions infection prevention practices used with all patients regardless of suspected or confirmed diagnosis. Based on the principle that all blood,
More informationHarrisburg, Pennsylvania. Assignment Description
Infectious Diseases-HAI Pennsylvania Department of Health, Bureau of Epidemiology, Healthcare-Associated Infections/Antibiotic Resistance (HAIAR) section Harrisburg, Pennsylvania Assignment Description
More informationHealthcare Associated Infections Know No Boundaries: A View Across the Continuum of Care
Healthcare Associated Infections Know No Boundaries: A View Across the Continuum of Care J. Hudson Garrett Jr., PhD, MSN, MPH, FNP, CSRN, VA-BC Vice President Clinical Affairs, PDI Healthcare Healthcare
More informationTuberculosis Prevention and Control Protocol, 2018
Ministry of Health and Long-Term Care Tuberculosis Prevention and Control Protocol, 2018 Population and Public Health Division, Ministry of Health and Long-Term Care Effective: January 1, 2018 or upon
More informationCMS Mega Rule: Implications for Pharmacists and Pharmacies
CMS Mega Rule: Implications for Pharmacists and Pharmacies Curt Wood, RPh, BCGP, FASCP Disclosure and Conflict of Interest Curt Wood declares no conflicts of interest, real or apparent, and no financial
More informationBridging the Gap Between Research and Practice in Long- Term Care An Innovative Model for Success
Bridging the Gap Between Research and Practice in Long- Term Care An Innovative Model for Success May 15, 2013 Sharon Bradley, RN, CIC Senior Infection Prevention Analyst Pennsylvania Patient Safety Authority
More informationThe role of HIQA in Quality Improvement in Long-Term Care. Bríd McGoldrick Inspector Manager HIQA
The role of HIQA in Quality Improvement in Long-Term Care Bríd McGoldrick Inspector Manager HIQA Overview Regulations and Standards Annual Overview Report 2015 Governance Communication Regulation Directorate
More informationInstitutional/Facility Outbreak Management Protocol, 2018
Ministry of Health and Long-Term Care Institutional/Facility Outbreak Management Protocol, 2018 Population and Public Health Division, Ministry of Health and Long-Term Care Effective: January 1, 2018 or
More informationSECTION: PATIENT RELATED INFECTION CONTROL NUMBER: 2.1 TRANSMISSION BASED PRECAUTIONS
University of Connecticut Health Center Page 1 of 8 SECTION: PATIENT RELATED INFECTION CONTROL NUMBER: 2.1 TRANSMISSION BASED PRECAUTIONS PURPOSE: Transmission-Based s are designed for patients documented
More informationInfection Control and Prevention On-site Review Tool Hospitals
Infection Control and Prevention On-site Review Tool Hospitals Section 1.C. Systems to Prevent Transmission of MDROs Ask these questions of the IP. 1.C.2 Systems are in place to designate patients known
More informationYale New Haven Health System Center for Healthcare Solutions
Table of Contents Yale New Haven Health System Center for Healthcare Solutions 2012 Winter/Spring Course Guide TOPICS center@ynhh.org www.ynhhs.org/chs Pages www.ynhhs.org/chs Page 0 Solutions for Healthcare
More informationKristi Felix RN, BSN, CRRN, CIC, FAPIC Infection Prevention Coordinator Madonna Rehabilitation Hospitals
Kristi Felix RN, BSN, CRRN, CIC, FAPIC Infection Prevention Coordinator Madonna Rehabilitation Hospitals Resident safety-priority for staff and for CMS Providing care in a homelike environment but still
More informationHealth Care Associated Infections in 2017 Acute Care Hospitals
Health Care Associated Infections in 2017 Acute Care Hospitals Christina Brandeburg, MPH Epidemiologist Katherine T. Fillo, Ph.D, RN-BC Director of Clinical Quality Improvement Eileen McHale, RN, BSN Healthcare
More information(a) Licensure. A facility must be licensed under applicable State and local law.
42 C.F.R. 483.705. Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental,
More informationReviewing regulatory requirements for top ten federal Nursing Home Tags issued in Minnesota. Eva Loch, MDH Nursing Evaluator
Reviewing regulatory requirements for top ten federal Nursing Home Tags issued in Minnesota. Eva Loch, MDH Nursing Evaluator F282- Comprehensive Care Plans Regulatory language (SOM): 483.21(b)(3) Comprehensive
More informationNursing Home Online Training Sessions Session 5: Clostridium difficile Part One: Clinical Overview
National Nursing Home Quality Care Collaborative Nursing Home Online Training Sessions Session 5: Clostridium difficile Part One: Clinical Overview Health Services Advisory Group (HSAG) Objectives 1 Welcome
More informationThe local health department shall maintain annually reviewed policies and procedures.
MPR 1 The local health department must have a system in place that allows for the referral of disease incidence and reporting information from physicians, laboratories, and other reporting entities to
More informationCMS and Joint Commission. Karen K Hoffmann RN MS CIC FSHEA FAPIC
CMS and Joint Commission Karen K Hoffmann RN MS CIC FSHEA FAPIC Disclaimer The views and opinions expressed in this lecture are those of this speaker and do not reflect the official policy or position
More informationAugust 28, Dear Ms. Tavenner:
August 28, 2013 Ms. Marilyn Tavenner Administrator Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue,
More informationThe Growing Threat of Antibiotic Resistance in Post-Acute Care
The Growing Threat of Antibiotic Resistance in Post-Acute Care Jennifer Han, MD, MSCE Assistant Professor of Medicine and Epidemiology Division of Infectious Diseases Associate Healthcare Epidemiologist
More informationCDPH HAI Program Overview
CDPH HAI Program Overview San Diego APIC Chapter San Diego January 11, 2017 Lynn Janssen, Chief Healthcare-Associated Infections Program Center for Health Care Quality California Department of Public Health
More informationGet Ready for Phase 1 of the New Requirements of Participation
Pennsylvania Health Care Association November 7, 2016 Get Ready for Phase 1 of the New Requirements of Participation Paula G. Sanders, Esquire Post & Schell, P.C. Gail Weidman Dawn Murr-Davidson Pennsylvania
More informationA university wishing to have an accredited program in adult Infectious Diseases must also sponsor an accredited program in Internal Medicine.
Specific Standards of Accreditation for Residency Programs in Adult Infectious Diseases 2016 VERSION 2.0 INTRODUCTION A university wishing to have an accredited program in adult Infectious Diseases must
More informationNew Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan 2010
New Jersey State Department of Health and Senior Services Healthcare-Associated Infections Plan Introduction The State of New Jersey has been proactive in creating programs to address the growing public
More informationConsumers Union/Safe Patient Project Page 1 of 7
Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several
More informationThe local health department shall maintain annually reviewed policies and procedures.
MPR 1 The local health department must have a system in place that allows for the referral of disease incidence and reporting information from physicians, laboratories, and other reporting entities to
More informationGet Ready for Phase 2: How to Use the Facility Assessment to Drive Person-Centered Care
Get Ready for Phase 2: How to Use the Facility Assessment to Drive Person-Centered Care Today s Objectives Analyze progress on major Arizona Nursing Home Quality Care Collaborative (NHQCC) goals. Describe
More informationInformRx. Transition from Hospital to the LTC Facility: Preventing Medication Errors to Reduce Risk of Hospital Readmission
CLINICAL & REGULATORY NEWS BY PHARMERICA NOV/DEC 2016 Transition from Hospital to the LTC Facility: Preventing Medication Errors to Reduce Risk of Hospital Readmission Transition from the hospital to the
More informationPhase 2: 4/24/2017. Implementation Phases. Objectives. Phase 1: November 28, Phase 3: November 28, 2019
NEW Requirements for Participation for Skilled Nursing Facilities The Elements of Compliance for Phase 2 April 28, 2017 1:30pm 2:45pm Objectives Identify the new and revised regulations in the Final Rule
More informationWhen is it really a UTI?
When is it really a UTI? Adrienne Mims, MD, MPH, FAAFP, AGSF VP, Chief Medical Officer Adrienne.Mims@AlliantQuality.org 2/19/2016 1 Disclosure This educational activity does not have commercial support
More informationFinancial Conflicts of Interest. Learning Objectives. Outline. Facts. LTC ASP Core Elements
THE LONG AND THE SHORT OF IT: DEVELOPMENT OF ANTIMICROBIAL STEWARDSHIP PROGRAMS IN LONG-TERM CARE FACILITIES Michael Tiberg, PharmD, BCPS (AQ ID) Nicholas Torney, PharmD, BCPS Derek Vander Horst, PharmD,
More informationEmergency Department Isolation Precautions
Carolinas HealthCare System Department of Infection Prevention I. SCOPE Emergency Department Isolation Precautions This policy applies to all Carolinas HealthCare System Emergency Department (ED) locations
More informationInfection Control (F441) F Cindy Deporter DHSR
483.80 Infection Control (F441) F 880-883 Cindy Deporter DHSR 1 2 3 4 Federal Regulatory Language 483.80 Infection Control F 880 The facility must establish and maintain an infection prevention and control
More informationClinical Intervention Overview: Objectives
AHRQ Safety Program for Long-term Care: HAIs/CAUTI Clinical Intervention Overview: Preventing Infections to Enhance Resident Safety Cohort 5 Learning Session #1 Steven J. Schweon RN, CIC APIC Infection
More informationKansas Heart and Stroke Collaborative
Sepsis in the Long Term Care Facility Aligning with Requirements of Participation Dr. Bob Moser, MD F.A.A.F.P Executive Director, Kansas Heart & Stroke Collaborative University of Kansas Health System
More informationLocal Health Department Access to the National Healthcare Safety Network. January 23, 2018
Local Health Department Access to the National Healthcare Safety Network January 23, 2018 Learning Objectives Describe the National Healthcare Safety Network (NHSN), its functions, and uses Identify upcoming
More informationSan Francisco General Hospital INFECTION CONTROL
San Francisco General Hospital INFECTION CONTROL SCOPE OF SERVICE 2009 The Infection Control Program at San Francisco General Hospital is a comprehensive quality improvement function that serves patients,
More informationSelf-Instructional Packet (SIP)
Self-Instructional Packet (SIP) Advanced Infection Prevention and Control Training Module 4 Transmission Based Precautions February 11, 2013 Page 1 Learning Objectives Module One Introduction to Infection
More informationCounty of Santa Clara Emergency Medical Services System
County of Santa Clara Emergency Medical Services System Policy # 700-S01 Ebola Virus Disease Prevention and Control EBOLA VIRUS DISEASE PREVENTION AND CONTROL Effective: December 8, 2014 Replaces: October
More informationC. difficile Infection and C. difficile Lab ID Reporting in NHSN
C. difficile Infection and C. difficile Lab ID Reporting in NHSN MARY ANDRUS, BA, RN, CIC Infection Preventionist Consultant Learning Objectives Review the structure and of the MDRO/CDAD Module within
More information5/9/17. Healthcare-Associated Infections Cultural Shift. Background. Disclosures and Disclaimers
National Center for Emerging and Zoonotic Infectious Diseases HAIs in Healthcare Settings: How Did We Get Here & What s Being Done to Address the Issue? Joseph Perz, DrPH MA Team Leader, Quality Standards
More informationCMS and NHSN: What s New for Infection Preventionists in 2013
CMS and NHSN: What s New for Infection Preventionists in 2013 Joan Hebden RN, MS, CIC Clinical Program Manager Sentri7 Wolters Kluwer Health - Clinical Solutions Objectives Define the current status of
More informationInfection Prevention Control Team
Title Document Type Document Number Version Number Approved by Infection Control Manual Section 3.1 Isolation Precautions and Infection Control Care Plan Policy 3 rd Edition Infection Control Committee
More information3/27/2017. SNF Requirements for Participation. Objectives. New Rules to Live By RoP Changes for 2017 and Beyond Sunday, April 2, :30 5:30pm
Disclosure of Commercial Interest Commercial Interest Employed by a consulting organization Name of Employer Pathway Health, Inc. Title Director of Quality and Government Services Description Pathway Health
More informationPatient Safety Course Descriptions
Adverse Events Antibiotic Resistance This course will teach you how to deal with adverse events at your facility. You will learn: What incidents are, and how to respond to them. What sentinel events are,
More informationCMS-3819-F Condition of participation: Reporting OASIS information. (a) Standard: Encoding and transmitting OASIS data. An HHA must encode
CMS-3819-F 319 OASIS information to the public. 484.45 Condition of participation: Reporting OASIS information. HHAs must electronically report all OASIS data collected in accordance with 484.55. (a) Standard:
More information3/6/2017. CMS nursing home requirements have not been comprehensively updated since 1991 despite significant changes in the industry.
Debra Brown, PharmD Pharmaceutical Consultant II Specialist Licensing and Certification QCHF/CAHF Spring Legislative Conference March 2017 1 Describe impact of 2016 CMS Final Rule on SNF pharmacy services
More informationCMS RULES FOR PARTICIPATION/LTC REGULATIONS: WHAT YOU NEED TO KNOW
CMS RULES FOR PARTICIPATION/LTC REGULATIONS: WHAT YOU NEED TO KNOW SATURDAY/3:15-4:15PM ACPE UAN: 0107-9999-17-242-L04-P 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacists:
More informationHealthcare-Associated Infections in North Carolina
2017 Annual Report May 2017 Healthcare-Associated Infections in North Carolina 2016 Annual Report Product of: N.C. Surveillance of Healthcare-Associated and Resistant Pathogens Patient Safety (SHARPPS)
More informationHealthcare-Associated Infections in U.S. Nursing Homes: Results from a Prevalence Survey Pilot
Healthcare-Associated Infections in U.S. Nursing Homes: Results from a Prevalence Survey Pilot Lisa La Place, MPH, Lauren Epstein, MD, Deborah Thompson, MD, Ghinwa Dumyati, MD, Cathleen Concannon, MPH,
More informationSpeaker Declarations
FSASC Quality and Risk Management Conference April 21, 2016 A Comprehensive Infection Prevention Program for An ASC Libby Chinnes, RN, BSN, CIC Infection Prevention and Control Consultant 1 Speaker Declarations
More informationCommunicable Diseases and Clusters of Communicable Diseases in School
Communicable Diseases and Clusters of Communicable Diseases in School Intended Audiences This document is intended primarily for school nurses. It is also useful for school administrators who are faced
More informationNew Strategies for Managing Medicare Risk
New Strategies for Managing Medicare Risk John Sheridan, MHSA, FACHE President, ehealth Data Solutions Keith Knapp, PhD, CFACHCA CEO, Christian Care Communities 1001. Survey and Certification Phase II
More informationBOV POLICY # 21 (2016) COMMUNICABLE DISEASE PROTOCOL
Policy Title: Communicable Disease Protocol Policy Type: Board of Visitors Policy No.: BOV Policy # 21 (2016) Approved Date: September 23, 2016 Responsible Office: Spartan Health Center Responsible Executive:
More informationHighlights of the New LTCSP and Regulations
Highlights of the New LTCSP and Regulations New York State Department of Health Division of Nursing Homes and ICF/IID Surveillance November 15, 2017 November 15, 2017 2 Resources https://www.cms.gov/medicare/provider-enrollment-andcertification/guidanceforlawsandregulations/nursinghomes.html
More informationWelcome to the Training Module for Mandatory Communicable Disease Reporting in Cuyahoga County, Ohio. Approximate time to complete this training is:
Welcome to the Training Module for Mandatory Communicable Disease Reporting in Cuyahoga County, Ohio. Approximate time to complete this training is: 15 minutes This training module is intended for healthcare
More information