1 2015 f undamentals o ctober 21 - 23, 2015 r oxanne p erry, rn, ms m anager i ntegrated p rograms...

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2015 FUNDAMENTALSOCTOBER 21 - 23, 2015

ROXANNE PERRY, RN, MSMANAGER

INTEGRATED PROGRAMS MANAGEMENT SECTION

Regulations for an Infection Prevention and

Control Program

Michigan Department of Health and Human Services

Medical Services Administration

Bureau of Medicaid Policy and Health System Innovation

Integrated Care Division

Integrated Programs Management Section

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Objectives

List at least 3 purposes for developing an effective infection prevention and control program.

List and describe Federal and State Infection Prevention & Control Regulations for different types of health care facilities.

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Historical Events 306-337 AD: Constantine the Great 1843: Oliver Wendell Holmes

1846: Ignaz Semmelweis

1860: Louis Pasteur 1867: Joseph Lister

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Historical Events

1800’s: Florence Nightingale

1837 – Committed herself to nursing

1845 – Entered nursing – cared for poor/indigent population

1851 – Official training/nursing career

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Historical Events

1854 – Crimean War – cleaned hospital equipment and reorganized patient care

1855 – Concluded that hospital deaths were due to poor living conditions

1950’s: Staphylococcal era 1959: First Infection Control Nurse

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Historical Events Change from Universal Precautions to Standard

Precautions

Isolation Practices – least restrictive

Hepatitis B Vaccine

HIV/AIDS

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Historical Events

MSIPC from MSIC

Influenza Vaccine

Pneumococcal Vaccine

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Why have an Infection Prevention & Control Program? Prevent and protect residents, employees,

volunteers & visitors from infections

Maximize quality of care

Avoid legal issues

Avoid adverse publicity

Comply with regulations and accreditation

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Regulations/Guidelines for the Prevention & Control of Infections

Federal GovernmentCenters for Medicare and Medicaid

Services (CMS)

Center for Disease Control (CDC)

Occupational Safety and Health Administration (OSHA)

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Regulations/Guidelines for the Prevention & Control of Infections State Government

Michigan Public Health Code

Licensing Rules

Communicable Disease Rules

Medical Waste Regulatory Program

MIOSHA

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Regulations/Guidelines for the Prevention & Control of Infections

Accreditation Entities

Association for Professionals in Infection Control and Epidemiology

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Federal and State RegulationsDepartment of Licensing and Regulatory Affairs

Bureau of Community and Health Services

Long Term Care – State and Federal

ICF/MR - Federal

Acute Care – State and Federal

CLIA Laboratories – State/Federal

Federal and State Regulations

Home Health – Federal

Ambulatory Surgical Clinics(ASC)/Freestanding Surgical Outpatient Facilities(FSOF) – State and Federal

End Stage Renal Disease - Federal

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Outpatient Physical/Speech Therapy Centers- Federal

Rural Health Clinics – Federal

Critical Access Hospitals – State and Federal

Comprehensive Outpatient Rehab Facilities - Federal

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Portable X-Ray Units – Federal

Hospice Residences – State and Federal

Hospice Agencies– State and Federal

Psychiatric Hospitals- State and Federal

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Long Term Care Infection Prevention/Control

Federal Regulations


F441§483.65 Infection ControlThe facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

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F441 continued

§483.65(a) Infection Control Program

§483.65(b) Preventing Spread of Infection

§483.65(c) Linens

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F334§483.25(n) Influenza and pneumococcal immunizations---(1) Influenza. The facility must develop policies and procedures that ensure that—(2) Pneumococcal disease. The facility must develop policies and procedures that ensure that—

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F281

483.20(k)(3)

The services provided or arranged by the facility must—

(i) Meet professional standards of quality...

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F520483.75(o) Quality Assessment and Assurance

(1) A facility must maintain a quality assessment and assurance committee consisting of-(i) The director of nursing services;(ii) A physician designated by the facility;

And(iii) At least 3 other members of the facility’s staff.

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F520 continued(2) The quality assessment and assurance committee-(3) State or the Secretary may not require disclosure of

the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.

(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

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F520 continued

Summary Identifies quality issues Establishes protocols Develops and implements corrective

actions Evaluate response

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Michigan Licensure Regulations

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Michigan Licensure RegulationRule 507

R 325.20507 Infection Control A written policy shall govern the control of

communicable disease and infections in the nursing home and shall require the establishment and operation of an Infection Control Committee, which shall include at least the director of nursing and representatives of administration, dietary, housekeeping, and maintenance services.

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R 325.20402Health of Employees and Others Providing Care

An employee on duty in the home shall be in good health and free from communicable disease.

An employee shall have an intradermal test for tuberculosis at the beginning of employment and annually thereafter. If at any time the skin test is positive, the local health department shall be notified and the employee shall have a chest x-ray to determine the presence of disease.

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R 325.20506 Tuberculosis Testing

The facility shall develop and implement policies governing the periodic intradermal tuberculin testing of patients in addition to the requirement for a chest x-ray on admission.

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Hospital Infection Prevention/Control

Federal Regulations

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A-0747

482.42 Condition of Participation: Infection Control

The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

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A-0748

482.42(a) Standard: Organization and Policies

A person or persons must be designated as infection control officers to develop and implement policies governing control of infections and communicable diseases….

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A-0748

482.42(a)(1) The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

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A-0749

482.42(a)…. The infection control officer or officers must maintain a log of incidents related to infections and communicable diseases.

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Hospital Infection Control

A-0756

482.42(b) Standard: Responsibilities of Chief Executive Officer, Medical Staff, and Director of Nursing Services

The chief executive officer, the medical staff, and the director of nursing must—

Hospital Infection Control

(1) Ensure that the hospital-wide quality assessment and performance improvement (QAPI) program and training programs address problems identified by the infection control officer or officers; and

(2) Be responsible for the implementation of successful corrective action plans in affected problem areas.

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Michigan Licensure Regulations

(Minimum Standards for Hospitals)


R 325.1021 (Rule 21)

Compliance with law and regulations

R 325.1022 (Rule 22)

Water and ice supply

R 325.1023 (Rule 23)

Sewage, garbage, and waste disposal

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R 325.1024 (Rule 24)

Laundering and sterilization of linens; Sterilization of instruments and utensils

R 325.1025 (Rule 25)

Heating and ventilating

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R 325.1026 (Rule 26) General maintenance.

R 325.1027 (Rule 27)

Patient Care.

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Infection Control ReferencesFederal Regulations

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_Appendixtoc.pdf

State Regulationshttp://www.michigan.gov/lara/0,4601,7-154-63294---,00.html

MSIPChttp://www.msipc.org/

1 2015 f undamentals o ctober 21 - 23, 2015 r oxanne p erry, rn, ms m anager i ntegrated p rograms...

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