please remember to put your phone on mute - oregon · disinfectant recommended, do not share...
TRANSCRIPT
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Agenda
Compliance Tips:
Compliance Trend Report
Hot Topics: Infection Prevention, Safe Injection
Manager’s Corner: Ana Potter
Compliance Tips Notification of administrator changes
Dave Mackowski
Understanding Staff Training
Learning Objectives
•
•
•
Common Deficiencies
• The facility does not have documentation training was completed;
• The facility has not provided training on all the required topics;• The facility did not ensure the training was completed within
the required timeframes.
Simplifying Training
1. Pre-Service Orientation
2. Competency Training
3. Annual In-Service Training
1. Pre-Service Orientation
• Residents' rights and the values of community-based care;
• Abuse and reporting requirements;
• Standard precautions for infection control; and
• Fire safety and emergency procedures.
Meeting the Rule - here’s what to do:
2. Competency Training
“The facility must have a training program that has a method to determine performance capability through a demonstration and evaluation process.”
Interpretations
Interpretations – First Aid & Abdominal Thrust
A Thought about Competency Training…
safely, effectively and consistently provide the required care to the residents in the facility.
Meeting the Rule - here’s what to do:
3. Annual In-Service Training
“All direct caregivers must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population.”
Interpretations
• However, survey will only count topics related to providing care to residents in CBC settings toward the required 12 hours of annual in-service training.
• Fire and Life Safety training, including fire drills, as required in OAR 411-054-0090, shall be provided in addition to the required 12 hours of annual in-service training. So fire safety doesn’t count.
Meeting the Rule - here’s what to do:
1. The topic(s) presented:
2. The amount of time spent on the topic(s):
3. The name of the staff who attended the training:
• Survey has to be able to read the employee’s name!
• The amount of time spent training on applicable topics (relating to resident care) needs to be clearly documented!
Example:
2:00 pm – 3:30 pm
• Total time: 60 minutes.
• Note that while the meeting itself was documented to be 1.5 hours long, only the transfer training would be counted as applicable training toward meeting the rule.
Memory Care Training
“A memory care community must ensure that staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs.
Interpretations
1. Pre-Service Orientation
2. Training to be completed within the first 30 days of hire
3. Annual In-Service Training
• In-Service training:
• Training to address the behavioral or health care needs of specific residents that could be utilized with future residents may be counted.
Meeting the Rule - here’s what to do:
Final Thoughts…
Thanks for your attention and participation!
CBC Survey TeamApril 2017
Compliance Trend ReportTop Ten Citations:1/1/2017-4/17/2017
1: 260 Service Plan (9)
2: 270 Change of Condition(7)
3: 303 Treatment Orders (7)
4: C310 Systems: Medications (7)
5: 280 Resident Health Services (6)
6: 370 Caregiver training (6)
7: C 252 Resident Move in (6)
8: C325 Self admin meds (5)
9: C 340 Restraints (5)
10: C 282 RN delegation(6)
999: Technical assistance (10)
Hot Topics-1
Infection prevention and Safe injection Practices Update
Infection Prevention and Safe Injection
Practices Update
Mary Post, RN, MS, CNS, CIC
Director, Infection Prevention
Oregon Patient Safety Commission
Roza Tammer, MPH, CIC
HAI Reporting Epidemiologist
Oregon Public Health Division
Acute and Communicable Disease Prevention
Healthcare-Associated Infections (HAI) Program
Objectives
• Highlight common findings from state wide on-
site infection prevention program consultations
• Review free general infection prevention
resources available to long-term care facilities
(LTCFs)
• Receive feedback on proposed Oregon Multi-
Drug Resistant Organism Toolkit (MDRO)
• Provide free injection safety educational
resources for long-term care facilities
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CDC Grant
• Focus: Build statewide infection prevention
infrastructure, capacity and education
• Funding for 100 onsite general infection
prevention consultations over three years
• To include healthcare facilities across the
continuum of care
• 13 LTCF consultations completed
• Consists of staff interviews, audits, observations,
and policy reviews
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Common Trends for LTCFs
• Hand hygiene-– Great to see increased hand sanitizer use- preferred
for general care
– Opportunity to improve- recommend audits
– Often forget to wash hands after glove removal
• Personal Protective Equipment (PPE)– Gloves available, but need to increase use of gowns
– Need to focus on increasing use of PPE
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Common Trends
• Respiratory/Cough Etiquette-– Signage available for respiratory outbreaks, but need
educational materials and supplies throughout the
year
• Antibiotic Stewardship Programs-– LTCF’s have started to address with policies and
practice
– Audits indicate orders frequently do not include
infection they are treating and date to discontinue
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Injection Safety and Point of Care
• Facilities not always using glucometer approved
for multi-resident use– Check manufacturer’s instructions for use (IFUs), if no
disinfectant recommended, do not share
• Need to use approved disinfectant for
recommended contact time
• IFUs need to be available on site– Available in kits, on company websites, or have letters from
company
• Success: Insulin pens, multi-dose vials, lancets
not being shared
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Interfacility Transfer
Communication• Need to strengthen intake and transfer
information for residents with MDROs and
special precautions
• Need to develop process to obtain culture
information when resident has been
admitted and/or transferred from facilityOregon Interfacility Transfer Communication
https://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/H
AI/Prevention/Pages/Interfacility-Communication.aspx
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Other Findings
• Many hats are worn by individual(s)
overseeing infection control program
• Environmental Services need additional
training– Disinfectant concentrations and dwell or contact times
– Sequence of room cleaning and bathroom cleaning,
including hand hygiene and glove use
– Focus on clean to dirty work flow
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12/13/201634
12/13/201635
Coming soon…. and free!
• Five statewide training programs for
Environmental Service Managers and/or
Supervisors
• Norovirus, C.difficile, Glucose Monitoring Videos
• 2-Day (for LTCFs) Fundamentals of Infection
Prevention Training Course-probably November
& February
• Webinars- lots of webinars!
• Sign-up for OPSC Newsletter
36
Thoughts
• Should Oregon develop an MDRO Toolkit
to include precautions and guidance for
long-term care facilities?
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Questions?
Mary T. Post, RN, MS, CNS, CIC
Oregon Patient Safety Commission
Injection safety in Oregon
• Current efforts include– Surveys assessing injection practices and drug
diversion prevention/response
– Infection Control Assessment and Response (ICAR)
– Member state: One and Only Campaign
• What’s coming?– Pilot project assessing patient risk and impact of
educational messaging on providers
– Communicable Disease Summary
Safe injection practices data
(Oregon SNFs)
98
87
7266
83
3044
5557
45
9 610 13
9
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Training upon hire? Annual training? Competency demo? Document competency? Audits?
Yes No Unsure
Does your facility have a drug diversion prevention
program that includes consultation with IP when drug
tampering is suspected or identified? (Oregon SNFs)
50.4% 30.7% 19.0%0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Yes
No
Unsure
CDC’s One & Only Campaign
• Goals– Raise awareness among patients and healthcare providers
about safe injection practices
– Eradicate outbreaks resulting from unsafe injection practices
• Oregon is a partner state – Conduct educational outreach, create state-based activities, and
further promote Campaign goals
42
Online resources
http://www.oneandonlycampaign.org/
http://www.cdc.gov/injectionsafety/
Print resources
45
46
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Promote membership
• Members of CDC’s One & Only Campaign – Professional and nonprofit organizations, healthcare
systems, provider groups, private companies
– Help raise awareness among patients and healthcare
providers about safe injection practices
– Promote and distribute campaign materials and
messages via print, video, and more
– Receive updates, recognition, and materials
– To join, email [email protected]
49
Follow us to learn more
Public Health Division’s social media accounts for
antibiotic stewardship and injection safety
• https://www.facebook.com/Oregon.aware
• https://www.twitter.com/OregonAWARE
50
Questions?
Roza Tammer, MPH, CIC
HAI Reporting Epidemiologist
Manager’s Corner
Ana Potter, Residential and Assisted Living Manager
Thanks so much!
Next News hour:
July 27th 2017
9:00 am
Questions????
[email protected] web site Address::
http://www.oregon.gov/DHS/PROVIDERS-PARTNERS/LICENSING/CBC/Pages/index.aspx