Welcome 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 2

INFECTION PREVENTION AND CONTROL: OVERVIEW OF THE NEW CMS RULES & SURVEY PROCESS Faculty Lynn Tabor MS, RN, WCC, IP-BC, ASCOM Director of Education & Training American Medical Technologies Taking the Pressure Out of Wound Care Since 1994 Copyright 2018 Gordian Medical, Inc. dba American Medical Technologies. www.amtwoundcare.com

Disclaimer L 4 This information is provided for informational purposes only. Patient management decisions should be based on a number of factors, including (but not limited to) professional society guidelines and published clinical literature relevant to a patient s condition. Providers are encouraged to rely on their training and expertise, as well as any and all available information, prior to making management or treatment decisions for any individual patient.

Objectives Overview Review the new infection prevention and control regulations, and suggest facility actions for preparing for the survey process related to these federal guidelines

CMS Final Rule Requirements for Long- Term Care Facilities Long-Term Care (LTC) Facilities have health and safety standards that facilities must meet in order to participate in the Medicare or Medicaid Programs. These standards include new mandates and language related to Infection Prevention and Control and Antibiotic Stewardship

F441- Replaced with F880, F881, F882, F883 Former Tag # New Tag # Tag Title F441 F880 Infection Prevention and Control New Tag F881 Antibiotic Stewardship Program New Tag F882 Infection Preventionist F334 F883 Influenza and Pneumococcal Immunizations

Minimum Elements for Compliance with Infection Control Mandates - F880 Facility must 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. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: A system for preventing, identifying, reporting, investigating, controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment Appendix PP November 22, 2017 State Operations Manual (SOM)

F881-Antibiotic Stewardship Mandate An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. NEW ABX regulations implemented November 28, 2017 (Phase 2) Resource Provided: State Operations Manual (SOM), Appendix PP-Revised Regulations and Tags, November 22, 2017

Surveyor Infection Control Work Sheet for LTC-1

Surveyor Infection Control Work Sheet for LTC-2

Antibiotic Stewardship Program As summarized by the CDC, the Core Elements for Antibiotic Stewardship in Nursing Homes include: Facility leadership commitment to safe and appropriate antibiotic use; Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship; Accessing pharmacists and others with experience or training in antibiotic stewardship; Implement policy(ies) or practice to improve antibiotic use; Track measures of antibiotic use in the facility (i.e., one process and one outcome measure); Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; and Educate staff and residents about antibiotic stewardship. Centers for Disease Control and Prevention. (2015). The core elements of antibiotic stewardship for nursing homes. Accessed on 10/20/17 from https://www.cdc.gov/longtermcare/prevention/antibioticstewardship.html

Leadership Commitment Education Reporting Core Elements Antibiotic Stewardship CDC Accountability Drug Expertise Tracking Action

Risks Associated with Lack of Preparedness for Infection Prevention and Control and Antibiotic Stewardship Programs Clinical Financial Risks Regulatory Legal

15 Infection Preventionist - F882 Qualifications of Infection Preventionist November 28 2019 IP must: (1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; (2) Be qualified by education, training, experience or certification; (3) Work at least part-time at the facility; (4) Has completed specialized training in infection prevention and control. IP participation on quality assessment and assurance committee. Copyright 2017 Gordian Medical, Inc. dba American Medical Technologies. Who is currently an IP Who is interest in becoming an IP

What to Do to Prepare for Your Infection Prevention and Control and Antibiotic Stewardship Programs??? Start gathering current resources CDC-documents Agency for Healthcare Research and Quality-AHRQ - Great documents CMS-Final Rule and State Operations Manual-November 2017 Evidence based infection prevention and treatment guidelines Find champions in your buildings who want to grow and mentor others in these areas-may become your infection preventionist Get your staff educated and skilled in infection prevention and control practices Ensure consultants/contract individuals familiar with IPCP and ASP Educate patients and families

Prepare, Prepare, Prepare Make it your goal to overprepare your staff

CMS Survey Perspective on Infection in LTC Facilities Factors for prevalence of infection in LTC building Understaffed facilities Staff without appropriate training, or time to prevent infections early Overtreatment with antibiotics Increasing clinician complexity of the average nursing home resident Frequent transitions between care settings leading to transmission of HAIs Lack of systematic approach to prevent and identify HAIs

Commonly Cited Deficiencies Hand hygiene Improper use of personal protective equipment (PPE) Isolation practices Dietary department sanitary issues Surveillance program Management of Clostridium difficile infection Environmental sanitation practices Attribution: Boot Camp For Long-Term Care Facility Infection Preventionist-2017

Be Prepared with Your Documentation Infection prevention and control (IPC) policies Have you IPC risk assessment and plan available Infection preventionist job description Quality Assessment and Assurance plan Any Root Cause analysis related to infection prevention practice issues Last quarter IP Surveillance data Base P&Ps on the Regulations, Standards of Care, Guidelines (e.g. CDC Core Elements)

Be Prepared with Policies Antibiotic Stewardship Program (ASP) policy Reports summarizing antibiotic use Antibiogram Hand hygiene policies and documentation of AUDITS Calculated rates of compliance Point of care policies and AUDITS on adherence to policy Glucometer cleaning Cleaning of equipment e.g., B/P cuffs, gait belts, sling (ALL equipment shared by residents!!!)

Be Prepared for Surveyor to Ask to See Your Policies Urinary tract infection prevention policies and policy for catheter use Cleaning and disinfection policies and AUDITS Employee Health policies including work-exclusion, reporting illness to supervisors, health screening for food handlers Influenza & Pneumococcal Vaccination Policy Vascular Access Policies Aerosol Transmissible Disease Policy and program

Documentation of Training The following can be requested upon entrance of surveyors to be received by the team within first 1-2 hours Specialized training for Infection Preventionist Personnel training on infection prevention (Standard Precautions, Transmission-based Precautions, blood borne pathogens, hand hygiene) Training on antibiotic use/stewardship to nursing staff & clinical providers Educational materials on ASP for residents and families Injection safety training and competencies

This is a LONG Road, no easy or fast way to accomplish. Lots of literature, webinars, courses, documents to assist with designing the process. See Reference Section Plan! READ the REGULATIONS! Take actions! Review/know your policies!!! Educate Observe (each other, competencies) Reach out for help (e.g. State, HCA) YOU CAN DO THIS!!!

Thank you!!!

General Infection Prevention References CDC Infection Prevention Resources for Long-term Care: http://www.cdc.gov/longtermcare CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/hai/prevent/prevent_pubs.html State Operations Manual. Appendix PP-Guidance to Surveyors for Long Term Care Facilities. Rev. 11-22-17 Healthcare Personnel Safety Guideline for Infection Control in Healthcare Personnel: http://www.cdc.gov/hicpac/pdf/infectcontrol98.pdf Immunization of HealthCare Personnel: http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html CDC Influenza Vaccination Tool-kit for Long-term Care Employers: http://www.cdc.gov/flu/toolkit/long-term-care/index.htm Occupational Safety & Health Administration (OSHA) Bloodborne Pathogen and Needlestick Prevention Standard: https://www.osha.gov/sltc/bloodbornepathogens/index.html

Hand Hygiene Guideline for Hand Hygiene in Healthcare Settings: http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene Examples of Hand Hygiene Auditing Tools: Measuring Hand Hygiene Adherence: Overcoming the Challenges: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf iscrub: http://compepi.cs.uiowa.edu/index.php/research/iscrub Personal Protective Equipment References 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006:http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings: http://www.cdc.gov/hai/prevent/ppe.html CDC Sequence for Donning and Removing Personal Protective Equipment: http://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention

References Safe Injection and Point of Care Testing Practices 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety CDC training video and related Safe Injection Practices Campaign materials: http://oneandonlycampaign.org Infection Prevention during Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html Environmental Infection Control Guidelines for Environmental Infection Control in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf EPA Listing of disinfectant products with sporicidal activity against C. difficile: https://www.epa.gov/sites/production/files/2016-06/documents/list_k_clostridium.pdf Options for Evaluating Environmental Infection Control: http://www.cdc.gov/hai/toolkits/evaluating- Environmental-Cleaning.html Resources to assist with evaluation and response to breaches in infection control Patel PR, Srinivasan A, Perz JF. Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control. 2008 Dec; 36(10); 685-90 http://www.ajicjournal.org/article/s0196-6553(08)00683-4/abstract Steps for Evaluating an Infection Control Breach: http://www.cdc.gov/hai/outbreaks/steps_for_eval_ic_breach.html Patient Notification Toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html

References Antimicrobial stewardship CDC Implementation Resources for Antibiotic Stewardship: http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html Respiratory Hygiene/Cough Etiquette 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html Respiratory Hygiene and Cough Etiquette in Healthcare Settings: http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm Recommendations for preventing the spread of influenza: http://www.cdc.gov/flu/professionals/infectioncontrol/

30 Literature and Tools on the CDC Website https://www.cdc.gov/longtermcare/prevention/ Core Elements Checklist of Core Elements Leading Antibiotic Stewardship in Nursing Homes[PDF - 379 KB] Creating A Culture to Improve Antibiotic Use in Nursing Homes[PDF - 331 KB] Infection Prevention in Aging: Resources These infection prevention and control resources were created for a patientcentered research study in nursing homes. A Targeted Infection Prevention (TIP) Intervention in nursing home residents with indwelling devices: a randomized clinical trial. AHRQ s Nursing Home Antibiotic Stewardship Tools and Guide Project

31 Resources Advancing Excellence infection control toolkit: https://www.nhqualitycampaign.org/goaldetail.aspx?g=inf S. Schweon, D. Burdsall, M. Hanchett, S. Hilley, D. Greene, I. Kenneley, J. Marx, P. Rosenbaum (2013). The Infection Perfectionist's Guide to Long-Term Care. APIC. Centers for Disease Control (CDC) toolkit for long-term care facilities: http://www.cdc.gov/longtermcare/index.html Centers for Disease Control (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibioticstewardship.html National Healthcare Safety Network (NHSN): Tracking Infections in Long- Term Care Facilities http://www.cdc.gov/nhsn/ltc/index.html

Federal Initiatives for Antibiotic Resistance 32 White House Forum on Antibiotic Stewardship National Action Plan for Combating Antibiotic-Resistant Bacteria Executive Order - Combating Antibiotic-Resistant Bacteria National Strategy to Combat Antibiotic-Resistant Bacteria PCAST Report on Combating Antimicrobial Resistance CDC report: Antibiotic Resistance Threats in the United States, 2013 Copyright 2017 Gordian Medical, Inc. dba American Medical Technologies.

INFECTION PREVENTIONIST IN LONG-TERM CARE BY JAN RUHL, RN, BSN, IPCO 2018 GOLDEN AGE NURSING FACILITY JRUHL@GOLDENAGEGUTHRIE.COM

NEW CMS REQUIREMENTS OF PARTICIPATION FOR INFECTION CONTROL Infection Prevention and Control Program (IPCP) must have: Required standards, policies and procedures 483.80 (Phase 1 effective November 28, 2016) Alignment with facility assessment (Phase 2 effective November 28, 2017) Antibiotic Stewardship Program (Phase 2 effective November 28, 2017) Infection Preventionist with Participation in QAPI Committee (Phase 3 effective November 28, 2019)

WHY IS INFECTION CONTROL A PRIORITY? Approximately 1 million individuals live in nursing center >100 days Increase risk of developing infections due to multiple chronic conditions, elderly, disabled 1-3 million serious infections occur every year in LTCF s and 380,000 die every year Difficult to diagnose infections due to lack of specific S&S and dementia 50-70% will receive a systemic antimicrobial agent during a calendar year 20-30% may receive multiple courses of antibiotics Antibiotics can cause serious harm MDRO s, C difficile, Adverse Reactions Serious outbreaks reported in LTC facilities norovirus, hepatitis, influenza, group A strep

INFECTION PREVENTIONIST (IP) Must designate one or more individual(s) as the IP(s) who is responsible for the facility s Infection Prevention and Control Program (IPCP) 1. Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field 2. Be qualified by education, training, experience or certification (i.e., CIC or IP-BC) 3. Work at least part-time at the facility 4. Have completed specialized training in infection prevention and control

INFECTION PREVENTIONIST JOB DESCRIPTION JOB DESCRIPTION - Is responsible to plan, organize, develop, coordinate and direct the Infection Prevention and Control Program - Include requirements for IP as per CMS guidelines (i.e, professional training, work PT at facility, education/training/certification/experience, specialized training in infection control and prevention) - Example provided

INFECTION PREVENTIONIST SPECIALIZED TRAINING CONTENT Infection prevention and control program overview Infection preventionist responsibilities Quality assessment and assurance committee Infection surveillance Outbreaks Hand hygiene Principles of standard and transmission-based precautions Linen management Water management Medication and sharps safety Respiratory etiquette Device and wound management Environmental cleaning, disinfection, and sterilization Vaccine-preventable respiratory infections and TB Employee and occupational health considerations Antibiotic stewardship program Infection prevention and antibiotic stewardship considerations during care transitions

Organization Title On-line? Length Certificate provided Cost American Health Care Association APIC NADONALTC CMS IPCO Infection Prevention Control Officer Training EPI in Long Term Care Certificate Series Infection Control and Mastery Program Specialized IPC Training for NH Staff in the LTC Setting Yes 23 hours Yes $450 member $650 non-member 2 day in person +3 on-line classes 16 + hours Yes State Dept of Health to provide unknown cost Yes 15 hours Yes $450 Yes (on demand) 16-20 hours Yes Free (Spring 2019)

INFECTION PREVENTIONIST PROFESSIONAL ORGANIZATIONS EPIC Epidemiologists and Preventionists in Infection Control Oklahoma City www.epicokla.com Monthly business meeting followed by educational presentation 3 rd Thursday of each month EPIC membership cost $25 annually Annual conference in OKC APIC Association for Professionals in Infection Control and Epidemiology National - https://apic.org Long Term Care section APIC membership cost $205 annually Comprehensive clinical education and professional development programs, free and discounted member resources, practical tips, and solutions. National annual conference

IP PARTICIPATION ON QUALITY ASSESSMENT AND ASSURANCE COMMITTEE The individual designated as the IP, or at least one of the individuals if more than one IP: 1. Must be a member of the facility s quality assessment and assurance committee 2. Report to the committee on the IPCP on a regular basis 3. To be implemented beginning November 28, 2019 (Phase 3)

ANTIBIOTIC STEWARDSHIP PROGRAM Intent is to: Optimize the treatment of infections by ensuring appropriate antibiotic prescribed Shall include: Antibiotic use protocols A system to monitor antibiotic use Reduce the risk of adverse events Develop, promote and implement a facility-wide system to monitor the use of antibiotics

ANTIBIOTIC STEWARDSHIP PROGRAM (CON T) CDC 7 Core Elements Leadership commitment demonstrate support and commitment formal statement Accountability identify leaders Drug Expertise pharmacist and others with ABS experience or training Action implement policies Tracking - measures of antibiotic use in the facility Reporting regular feedback to physicians and staff Education for residents, families, staff and physicians

ANTIBIOTIC STEWARDSHIP PROGRAM (CON T) Antibiotic Use Protocols Criteria met for clinical definition of active infection or suspected sepsis Define which criteria you are using i.e., NHSN, McGeer Revised 2012 Pathogen susceptibility Based on culture and sensitivity to antimicrobial (or therapy begun while culture is pending) Complete antibiotic orders Drug, dose, frequency, duration of treatment, route, indication for use Infection assessment tool or management algorithm i.e., SBAR

ANTIBIOTIC STEWARDSHIP PROGRAM (CON T) Utilize communication tools to guide communication between nursing home staff and prescribing clinicians about the potential need for antibiotics for residents Examples of antibiotic use protocols, policies and practices developed by the Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/nhguide/index.html Nursing Home Antimicrobial Stewardship Guide Toolkits - cover a variety of interventions that nursing homes can use to improve antibiotic use SBAR forms (example) Situation Background Assessment Recommendation

ANTIBIOTIC STEWARDSHIP PROGRAM (CON T) A System to Monitor Antibiotic Use Reports related to monitoring antibiotic usage and resistance data Summarize antibiotic use from pharmacy data such as the rate of new start or days of antibiotic treatment per 1,000 resident days (# of new starts or antibiotic days divided by # total patient days x 1000) or types of antibiotics prescribed Summarizing antibiotic resistance (e.g. antibiogram) based on lab data Tracking measures of outcome surveillance related to antibiotic use (e.g. C difficile, MRSA, CRE)) Feedback to prescribing practitioners on prescribing practices and compliance with facility antibiotic use protocols Include the mode and frequency of education for prescribing practitioners and nursing staff on antibiotic use and protocols

ANTIBIOTIC STEWARDSHIP PROGRAM (CON T) The assessment, monitoring, and communication of antibiotic use shall occur by a licensed pharmacist. A pharmacist must perform a medication regimen review (MRR) at least monthly, including review of the medical record and identify any irregularities, including unnecessary drugs. Include the Pharmacy monthly review in your Infection Control Committee/QAPI meeting minutes (i.e.,the MRR by the consulting Pharmacist included the review of the Antibiotic Stewardship Program and is currently tracking antibiotic usage and what irregularities were identified, if any.)

SURVEY OF ANTIBIOTIC STEWARDSHIP PROGRAM Surveyors will determine whether the facility s ABS program includes: Antibiotic use protocols addressing antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of antibiotic, review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted, an infection assessment tool or management algorithm is used when prescribing) A system to monitor antibiotic use (i.e., antibiotic use reports, antibiotic resistant reports)

RESOURCES FOR INFECTION PREVENTION AND CONTROL PROGRAM CDC www.cdc.gov/longtermcare an abundance of infection control information for long term care including staff, resident, and family educational handouts, facility assessment tool CMS www.cms.gov conditions of participation 483.80 Infection Control Oklahoma State Department of Health - www.ok.gov/health - Reportable Diseases list, TB assessment, multiple other infection control information for long term care Med-Pass www.med-pass.com Infection Control Policy and Procedure Manual for Long Term Care a guideline in meeting compliance with OBRA, AHSA, CDC, FDA and JCAHO regulations Resources for Reform Requirements for Long-Term Care Facilities 483.80 Infection Control - http://www.health.state.mn.us/divs/fpc/profinfo/022717callfile4.pdf Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria 2012 - http://www.jstor.org/stable/10.1086/667743 ASAP Nebraska DHHS Epidemiology Unit Revised McGeer Criteria for Infection Surveillance Checklist - https://asap.nebraskamed.com/.../revised-mcgeer-criteria-for-infection-surveillance-c...

Emergency Preparedness It Doesn t Have to be a Disaster 50

Questions? 51

Thank You John Leon, RN MPH Nursing Home Quality Improvement Specialist 405-302-3248 jleon@ofmq.com Funding is provided by the Civil Monetary Revolving Fund ( 63-1-107.4), grant number 3409021528, Office of Protective Health Services, Oklahoma State Department of Health (OSDH). OSDH is an equal opportunity employer and provider. This publication is issued and authorized by OSDH. Copies have not been printed but are available on the OSDH website at www.health.ok.gov. JAN 52 2018 Graphics Design: OFMQ