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 to be colonized or infected with a targeted MDRO including C. auris and to notify receiving units and personnel prior to movement of such patients within the hospital. 1.C.4 The hospital can provide a list of target MDROs including C. auris. te: Hospitals should able to provide a list of MDROs including C. auris that are targeted for infection control because they are epidemiologically important (e.g., MRSA, VRE). Please refer to CDC s Guideline for Isolation Precautions for criteria that may be used to define epidemiology important organisms: http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf. 1.C.7 The hospital has evidence of an established system(s) to ensure prompt notification to the Infection Control Officer when a novel resistance pattern or novel organism based on microbiology results is detected. 1.C.8 Patients identified as colonized or infected with target MDROs including C. auris are placed on Contact Precautions. te: This does not imply that hospitals are required to perform active surveillance testing to detect MDRO colonization among a specific subset or all patients. Describe how surveillance is done for target MDROs in real or near-real time? How are individual patients with targeted MDROs identified or flagged so appropriate precautions can be applied at readmission? Section 1.D. Infection Prevention Systems, and Training Related to Personnel
1.D.11 Personnel competency and compliance with job specific infection prevention policies and procedures are ensured through routine training and when the Infection Control Officer has identified problems requiring additional training. Describe how the facility ensures personnel competency with hand hygiene, use of PPE, and cleaning and disinfection of equipment? Includes both clinical staff and Environmental Services staff. Section 2.A. Hand Hygiene (Observation) Hand hygiene is performed in a manner consistent with hospital infection control practices, policies, and procedures to maximize the prevention of infection and communicable disease including the following: 2.A.1 Soap, water, and a sink are readily accessible in appropriate locations including, but not limited to, patient care areas and food and medication preparation areas. te: Medications should not be prepared near areas of splashing water (e.g. within 3 feet of a sink). Alternately when space is limited, a splash guard can be mounted beside the sink. 2.A.2 Alcohol - based hand rub is readily accessible and placed in appropriate locations. The locations may include: Entrances to patient rooms, at the bedside, in individual pocket - sized containers carried by healthcare personnel, staff workstations, and/or other convenient locations. 2.A.4 Personnel perform hand hygiene: after contact with the patient, after contact with blood, body fluids, or visibly contaminated surfaces, after removing gloves. Ask facility staff when to use alcohol based hand rub versus soap and water.
2.A.5 Personnel perform hand hygiene using soap and water when hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus. te: In most other situations, alcohol - based hand rub is preferred. 2.A.6 Personnel do not wear artificial fingernails and/or extenders when having direct contact with patients at high risk of infection. Ask the IP how hand hygiene adherence is monitored and how feedback is provided. Section 2.C. Personal Protective Equipment/Standard Precautions (Observation) 2.C.1 Supplies for adherence to Standard Precautions using personal protective equipment (e.g., gloves, gowns, mouth, eye, nose, and face protection) are available and located near point of use. 2.C.4 Gowns are worn to prevent contamination of skin and clothing during procedures/activities where contact with blood, body fluids, secretions, or excretions could occur. 2.C.5 Gowns and gloves are removed and hand hygiene is performed: before leaving the patient s environment (e.g. including moving to another patient). Section 2.D. Environmental Services (Observation terminal and daily cleaning of patient rooms) (Ask questions of the IP, clinical staff, and/or environmental staff, as appropriate.) 2.D.1 During environmental cleaning procedures, personnel wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection).
2.D.2 Environmental surfaces in patient care areas are cleaned and disinfected, using an EPA - registered disinfectant registered for use in health care facilities on a regular basis (e.g., daily), when spills occur and when surfaces are visibly contaminated. For C. difficile and C. auris, facility uses products labeled as effective against C. difficile. te: High - touch surfaces (e.g., bed rails, over - bed table, bedside commode, lavatory surfaces in patient bathrooms) should be cleaned and disinfected more frequently than minimal - touch surfaces. 2.D.3 After a patient vacates a room, all visibly or potentially contaminated surfaces are thoroughly cleaned and disinfected and towels and bed linens are replaced with clean towels and bed linens. 2.D.4 Cleaners and disinfectants, including disposable wipes, are used in accordance with manufacturer s instructions (e.g., dilution, storage, shelf - life, contact time). 2.D.5 Separate clean (laundered if not disposable) cloths are used to clean each room and corridor. 2.D.6 Mop heads and cleaning cloths are laundered at least daily using appropriate laundry techniques (e.g., following manufacturer instructions when laundering microfiber items). Is environmental cleaning and disinfection routinely monitored in your facility? (ask IP these questions) By whom? If so, how do you measure effectiveness? If monitored, is feedback provided to staff? Which cleaning products are used in your facility, under what circumstances are each of them used, and what is the contact time for each? te: Ask infection preventionist(s), clinical staff (e.g. nurses), and environmental services. Wait to ask environmental services staff until after you watch at least one of them clean a room. (Infection preventionists should at a minimum know to use a product with a claim for Clostridium difficile spores for C. auris. If caring for patients with C. auris, then clinical staff and environmental services staff should also know to clean rooms of those patients with products
with a claim for C. difficile spores. Environmental services staff and clinical staff should know the contact time for the products they use and which are appropriate for C. difficile.) Observe daily and/or terminal cleaning and disinfection of a room housing a person with C. auris if possible, or otherwise housing a person with C. difficile, or otherwise housing a person on Contact Precautions, or otherwise any room) -Appropriate product used (EPA-registered hospital grade disinfectant; claim for Clostridium difficile spores for rooms of patients with Clostridium difficile or C. auris) -High-touch surfaces/objects (e.g. bed rails, over-bed table, bedside commode, surfaces in patient bathrooms) are cleaned and disinfected at least daily and when visibly soiled -Appropriate contact time for product is followed Links with (Source: CMS ICWS 4.F.11) and (Source: CMS ICWS 2.D.2) After observation of cleaning and disinfection, ask environmental services staff how many rooms they are expected to clean in what amount of time. Response should be consistent with the time taken to clean the room observed and with the contact time of the product used. Reprocessing of non-critical items is accomplished in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following: 2.D.14 Reusable noncritical patient care devices (e.g. blood pressure cuffs, oximeter probes) are disinfected on a regulator basis (e.g. after use on each patient, once daily, or once weekly) and when visibly soiled. Which cleaning products do you use for reusable noncritical items, under what circumstances are each of them used, and what is the contact time for each? te: Ask infection preventionist(s), clinical staff (e.g. nurses), and environmental services. Answers should be consistent to avoid confusion about who cleans what equipment.
2.D.15 For patients on Contact Precautions, if dedicated, disposable devices are not available, noncritical patient-care devices are disinfected after use on each patient. 2.D.16 There is clear designation of responsibility for disinfection of reusable noncritical patient-care devices. Who is responsible for cleaning equipment that is shared between patients (e.g. blood pressure cuffs, computers on wheels, mechanical lifts, ventilators, PT/rehab equipment)? (Ask IP, frontline clinical staff, and environmental services staff answers should be consistent and cover all equipment) Follow up question to staff responsible for cleaning: How such equipment is to be cleaned and disinfected? 2.D.17 Manufacturers instructions for cleaning noncritical medical equipment are followed. Section 4.C. Ventilator/Respiratory Therapy The facility considers ventilators a high touch surface area when in use and assesses the frequency of cleaning during use. Section 4. E. Point of Care Devices (e.g. Blood Glucose Meter, INR monitor) 4. E.3 Finger stick devices are not used by more than one patient. te: This includes both the lancet and the lancet holding device 4. E. 4 If used for more than one patient, the point-of-care testing device (e.g. blood glucose meter, INR monitor) is cleaned and disinfected after every use according to manufacturer s instructions. te: if manufacturer does not provide instructions for cleaning and disinfecting, then the device should not be used for more than one patient. Section 4.F. Isolation: Contact Precautions (Observation) 4.F.1 Patient with known or suspected (C. diff or C. auris) infections or with evidence of syndromes that represent an increased risk for contact transmission are placed on Contact Precautions.
4.F.2 Gloves and gowns are available and located near point of use. 4.F.3 Signs indicating patient is on Contact Precautions are clear and visible. 4.F. 4 Patients on Contact Precautions are housed in single patient rooms when possible or cohorted based on a clinical risk assessment. Ask how single rooms are assigned. 4.F.5 Hand hygiene is performed before entering patient care environment. te: Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected candida auris, C. difficile or norovirus. In most other situations, alcohol-based hand rub is preferred. 4.F.6 Gloves and gowns are donned upon entry into the room or cubicle. 4.F.7 Gloves and gowns are removed and discarded, and hand hygiene is performed before leaving the patient care environment. 4.F.8 Dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs) is used, or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturers instructions. 4.F.9 The hospital limits the movement of patients on Contact Precautions outside of their room to medically necessary purposes only. 4.F.10 If a patient on Contact Precautions must leave their room for medically necessary purposes, there are methods followed to communicate that patient s status and to prevent transmission of infectious disease.
Is PPE adherence measured? If yes, how is feedback returned? (Ask IP) What types of PPE would be used for: Droplet Contact Airborne te: Ask clinical staff, e.g. CNAs and environmental services. When or where (if at all) may staff enter a room with a patient on Contact precautions without donning PPE? Example of unacceptable answers: immediately after room cleaned, if you don t expect to touch the patient. (Acceptable answers will depend on facility policy.) Z. Interfacility Communication Can be in HERDS Z.1 The hospital has a process and can demonstrate evidence that communication of patient infection, colonization or known history of positive culture with multidrug-resistant organism, C. difficile, or other epidemiologically important organism (e.g. scabies) is prominently indicated to receiving provider before or at the time of transfer? Z.2 The hospital has a process and can demonstrate evidence that communication of the presence of clinical signs or symptoms of potentially communicable diseases (e.g., vomiting, diarrhea, cough) is sent to receiving provider before or at the time of transfer? Z.3 The hospital has a process and can demonstrate evidence that communication of the rationale and use of transmission-based precautions/ppe is sent to receiving provider before or at the time of transfer (e.g. C difficile with diarrhea)? Z.5 The hospital has a process for and can demonstrate evidence that they have sent additional information about potentially transmissible infections, resistant organisms, and antibiotic use to the receiving provider, as soon as available, if missing or unavailable at the time of patient arrival at the receiving provider. Z.6 The hospital has evidence that essential information about potentially transmissible infections, resistant organisms, and antibiotic use is reviewed and addressed (e.g. transmission-based precautions) at the time of patient arrival from a transferring facility (e.g. nursing home)? What does your facility do if such documentation is not received? If your facility admits a patient from a sending facility and detects a potentially transmissible infection, does it inform the sending facility?
te any general breaches of Infection Control practice not otherwise captured by this tool:
Observations and Questions for Staff (LTCFs) A. Infection control program, infrastructure, and personnel 1. Policy Review The facility has an infection control program with written policies and procedures. 10 NYCRR 415.19(a) The facility policies and procedures address: 10 NYCRR 415.19 - Investigation, controls and actions to prevent infections - How to determine which level of precautions should be utilized and when - A system for maintaining a record of incidence and corrective actions related to infections The facility has evidence of mandatory personnel infection prevention and control training. 10 NYCRR 415.13(c)(6)(a)(2) and 415.26(c)(3) 2. Questions to ask the IP/ICP Responses What training have you received in infection control? Does your facility support additional training for you and any other infection control staff working here? If so, how? Please describe how information about infections in the facility are transmitted to responsible staff (e.g. infection preventionists, clinicians, nurses and CNAs). Does your facility have someone in the IP role in the HCS directory? 1
B. Surveillance and Stewardship 1. Policy Review The facility has a written surveillance plan, based on the risk assessment, outlining activities for monitoring/tracking infections occurring in residents of the facility. 10 NYCRR 415.19(a)(3) The facility investigates, controls and takes action to prevent infections in the facility; 10 NYCRR 415.19(a)(1) The facility maintains a record of incidence and corrective actions related to infections. 10 NYCRR 415.19(a)(3) The facility ensures a resident with a communicable disease is not admitted or retained unless a physician certifies in writing that transmissibility is negligible, and poses no danger to other residents, or the facility is staffed and equipped to manage such cases without endangering the health of other residents; 10 NYCRR 415.26 The facility provides laboratory services to meet the needs of its residents. 10NYCRR 415.20 The facility ensures laboratory reports are received and reported to the physician in a timely manner. 10NYCRR 415.20 and 415.21 The facility can demonstrate knowledge of when and to whom to report communicable diseases, healthcare associated infections (as appropriate), and potential outbreaks. 10 NYCRR 415.19(d) 2. Questions to ask the IP/ICP/ Medical Director Responses Do you currently have any residents on transmission precautions? 2
If residents are on Transmission Precautions, please identify the MDRO ( e.g. C. Auris, MRSA) How do you identify and track infections and antibiotic use in the facility? If a resident is on transmission precaution, how is this communicated to the staff and visitors? Interview direct care staff to determine their understanding and knowledge of the precautions used in the facility. Has this facility implemented any components of antimicrobial stewardship? Follow-up question: If yes, what are you doing? If no, what are your plans in this regard? 3
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C. Interfacility Communication 1. Record Review The facility ensures complete documentation in the resident's clinical record when the facility transfers or discharges a resident. 10 NYCRR 415.3 The facility provides for the transfer of medical and other information needed for care and treatment of residents, when the transferring facility deems it appropriate. 10 NYCRR 415.26 When a resident is transferred to another facility, the facility ensures sufficient communication of health conditions (including pertinent diagnoses, infection control risks and medications) to the receiving facility consistent with generally accepted standards of practice. 10 NYCRR 415.1 2. Questions to ask the IP/ICP Responses If a resident is being transferred to another facility, does resident documentation sent to the receiving facility providers include infection control information? If so does it indicate: - the specific organism(s) the resident is known to be infected or colonized with? -the presence of any other epidemiologically important organism (e.g. scabies)? -Which, if any, Transmission-based Precautions are being used and the rationale for Precautions? If your facility is receiving a resident who is being transferred from another facility, is essential infection control information reviewed and addressed at the time of arrival? 5
If so does that review include determining: - the specific organism(s) the resident is known to be infected or colonized with? -the presence of any other epidemiologically important organism (e.g. scabies)? -Which, if any, Transmission-based Precautions are being used and the rationale for Precautions? If infection control information is not provided by a transferring facility, does your facility have a process for obtaining the necessary information? If so, please describe. If yes, please describe: The facility has a system to follow up on infection control-related clinical information when residents are transferred to acute care hospitals for management of suspected infections, including sepsis, to ensure that organisms of infection control importance are identified (e.g. C. difficile or MDROs identified upon admission may indicate a need for special cleaning and disinfection of the resident s room) If yes, please describe: 6
D. Hand Hygiene 1. Policy Review All personnel receive training on HH at the time of employment. 10 NYCRR 415.13(c)(6)(a)(2) and 415.26(c)(3) The facility provides continuous staff development programs to increase staff knowledge, skills. 10 NYCRR 415.26(c)(2)(iii) The facility requires physicians and staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. 10 NYCRR 415.19 Personnel handle, store, process, and transport linens to prevent the spread of infection. 10 NYCRR 415.19 If contact precautions are modified such that the resident can leave the room, ask the following: When being assisted by healthcare personnel, resident hand hygiene is performed: Prior to resident leaving room if on transmission-based precautions After toileting Before meals 2. Questions to ask the IP/ICP Responses Is hand hygiene adherence monitored in your facility? If so, which categories of staff are monitored? Nursing PT/OT ) Clinicians Env. Services Dietary/nutrition including foodpreparers and servers Contract staff (e.g. dialysis, resp, therapy, phlebotomy) Others (please specify): 7
If monitored, is feedback provided to staff? If yes, please describe how: Questions to ask frontline staff (CNAs, EnvS, etc.) When would you use alcohol-based hand rub vs. soap and water? Responses Please describe any training and competency evaluation (e.g. observations of practices) you received by the facility upon hiring and in the past 12 months related to hand hygiene. 3. Observations Responses Hand hygiene supplies (sink, soap, hand rubs) are readily accessible and placed in appropriate locations. If yes, please describe: 8
Observe hand hygiene compliance throughout the facility. Do all staff follow facility policies? If no, please explain: Is it performed at a minimum (and even if gloves are used): 1) before and after contact with the resident; 2) before performing an aseptic task; 3) after contact with body fluids or visibly contaminated surfaces; 4) after contact with objects/surfaces in resident s environment; 5) after removing PPE. Do residents, when assisted by healthcare personnel, perform hand hygiene before leaving room if on transmission-based precautions, after toileting, and before meals? If no, please explain: If no, please explain: 9
E. Standard/Transmission-based Precautions and PPE 1. Policy Review The facility determines what procedures such as isolation and standard precautions should be utilized for an individual resident and implements the appropriate procedures to be followed to prevent spread of infections; which includes selection and use of PPE (e.g., indications, donning/doffing procedures) and specifies the clinical conditions for which specific PPE should be used (e.g., C. difficile, Influenza). 10 NYCRR 415.19(a)(2) Residents with known or suspected infections, or with evidence of symptoms that represent an increased risk for transmission, are placed on the appropriate transmission based precautions. 10 NYCRR 415.19(a)(2) The facility limits the movement of residents (in accordance with policies) on transmission-based precaution with active symptoms (diarrhea, nausea and vomiting, draining wounds that cannot be contained for highly infectious diseases (e.g. norovirus, C difficile)) outside of their room for medically necessary purposes only. 10 NYCRR 415.19(b)(1) The activities program director ascertains, initially from the resident's attending physician, and on an ongoing basis from other appropriate professional staff, which residents are not permitted for specific documented medical reasons, to participate in certain activities. 10 NYCRR 415.5 2. Interviews Responses Is PPE adherence monitored in your facility? If so, which categories of staff are monitored? Nursing PT/OT ) Clinicians Env. Services Dietary/nutrition including foodpreparers and servers Contract staff (e.g. dialysis, resp. therapy, phlebotomy) Others (please specify): 10
If monitored, is feedback provided to staff? If yes, please describe how: Questions to ask frontline staff (CNAs, EnvS, etc.) Please describe any training and competency evaluation (e.g. observations of practices) received by the facility upon hiring and in the past 12 months related to Transmission-based Precautions and PPE Responses Please describe the difference between Standard and Transmission-based Precautions. In addition to Standard Precautions, when would you use PPE? (Examples of appropriate responses: gown for uncontained secretions or excretions; appropriate mouth, nose, and eye protection for procedures likely to generate splashes or sprays) Based on Transmission-based Precautions signs and readily-available related information, frontline staff can verbalize: -Which resident the sign applies to -Which type of Transmission-based Precautions the resident is on -Which PPE is indicated -When/where (if at all) staff may enter a room with resident(s) on Transmission-based Precautions without donning PPE (Unacceptable answers: immediately after room cleaned, if don t expect to touch resident) -Who is responsible for stocking and re-stocking PPE supplies - 11
3. Observations Responses Supplies necessary for adherence to Standard and Transmission-based precautions (e.g. gloves, gowns*) are readily available, in adequate If no, please explain: quantities, to staff in resident care areas. This includes having supplies immediately accessible to anyone entering the room of a resident(s) on Transmission-based precautions. *Check gowns (long sleeved arms) are being used and not aprons. PPE are worn/removed as appropriate (gowns are pulled up to shoulders, secured and not drooping). This includes: If no, please explain: Wearing them if contact with body fluid, mucous membranes, non-intact skin is expected; Removing them after such contact; Changing them and performing hand hygiene before moving from contaminated-body site to clean body site; and Wearing them for direct resident contact if resident has uncontained secretions or excretions Residents with known or suspected C. Auris or other MDROs are on Contact Precautions. If no, please explain: (te: May be modified to allow resident to leave room.) Residents with known or suspected C. Auris or MDROs are housed in single rooms or cohorted with another resident(s) with known or suspected C. Auris or MDRO If no, please explain: Residents with a known or suspected infection have pertinent signage posted or an effective system in place to recognize a resident needs precautions that alerts both staff and visitors while preserving the resident s confidentiality. Staff entering and exiting room(s) of resident(s) on Contact Precautions (preferably a resident with C. Auris, if available) do the following tasks: If yes, please describe the signs being used: If no, please explain: -Hand hygiene performed before entering -Gowns and gloves are donned upon entry. Gowns are worn correctly (e.g. tied) 12
-Dedicated or disposable equipment is used or, if not available, is cleaned and disinfected per manufacturer s instructions before use on another resident (a sporicidal agent should be used for residents with C. Auris) -Gowns and gloves are removed and properly discarded upon leaving the room -Hand hygiene is performed upon leaving the room -PPE appropriately discarded after resident care before leaving room, then hand hygiene performed. 13
F. Environmental Cleaning 1. Policy Review The facility has cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms, and high-touch surfaces in common areas. The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.) The facility ensures all equipment and supplies are cleaned and properly sterilized where necessary and are stored in a manner that will not violate the integrity of the sterilization. 10 NYCRR 415.19(b)(2) N/A The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, are clean. 10 NYCRR 415.29 The facility separately bags or encloses used linens from residents with a communicable disease in readily identifiable containers distinguishable from other laundry. 10 NYCRR 415.29 Supplies necessary for appropriate cleaning and disinfection procedures using an EPA-registered disinfectant approved for use in healthcare facilities on a regular basis (e.g. daily) as well as when spills occur and surfaces are visibly contaminated. For C. difficile and C. Auris, facility uses products labeled as effective against C difficile. te: If environmental services are performed by contract personnel, facility should verify that appropriate EPA-registered products are provided by contracting company 14
2. Questions to ask the IP/ICP Responses Is environmental cleaning and disinfection routinely monitored in your facility? If no, under what situations would it be done? If so, how do you measure effectiveness? Check all that apply: Direct observation Fluorescent markers ATP bioluminescence Other (please specify): If monitored, is feedback provided to staff? If yes, please describe how: Who is responsible for cleaning equipment that is shared between residents (e.g. blood pressure cuffs, computers on wheels, mechanical lifts, ventilators, PT/rehab equipment), and how do they know which product to use? Please tell me which cleaning products are used in your facility and under what circumstances are each of them used? (-Should at a minimum know to use a product with a claim for Clostridium difficile spores for C. difficile or C. Auris - Resident(s) on a ventilator with C-Diff or C. Auris, check if manufacturer s recommendations for cleaning ventilator align with above). 15
Questions to ask frontline staff (CNAs, EnvS, etc.) Who is responsible for cleaning equipment that is shared between residents (e.g. blood pressure cuffs, computers on wheels, mechanical lifts, ventilators, PT/rehab equipment). Responses Follow up question to staff responsible for cleaning: How such equipment is to be cleaned and disinfected? Please tell me which cleaning products are used in your facility and under what circumstances are each of them used? (Should at a minimum know to use a product with a claim for Clostridium difficile spores for C. difficile or C. Auris) Follow up question for environmental services staff: How are each of these product(s) prepared? How much time are they good for before you need to make a fresh batch? (Responses above should be consistent with product labels) 3. Observations Responses Observe daily and/or terminal cleaning and disinfection of a room (housing a person with C. Auris if possible, or otherwise housing a person on Contact Precautions, or otherwise any room) -Appropriate product used (EPA-registered hospital grade disinfectant; claim for Clostridium difficile spores for rooms of residents with Clostridium difficile or C. Auris) -For rooms of residents on Contact Precautions, high-touch surfaces/objects (e.g. bed rails, over-bed table, bedside commode, surfaces in resident bathrooms) are cleaned and disinfected at least daily and when visibly soiled -Appropriate contact time for product is followed 16
After observation of cleaning and disinfection, ask environmental services staff how many rooms they are expected to clean in what amount of time. Response should be consistent with the time taken to clean the room observed and with the contact time of the product used. IP and environmental services frontline staff can verbalize what the contact time is for the products they use. 17