This facility task must be used to investigate compliance at F880, F881, F882, F883, and F887. For the purpose of this task, “staff” includes facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility’s nurse aide training programs or from affiliated academic institutions. The infection prevention and control program (IPCP) must be facility-wide and include all departments and contracted services. If a specific care area concern is identified, it should be evaluated under the specific care area such as for pressure ulcers, respiratory care, catheter care, and medication pass observations.
Focused Infection Control (FIC) Survey (not associated with a recertification):
Surveyors must evaluate the facility’s compliance at all critical elements (CE) in this pathway with the exceptions of CE#4 (Water Management), CE#5 (Laundry Services), and CE#6 (Antibiotic Stewardship Program).
Coordination:
☐ Each surveyor is responsible for assessing the facility for breaks in infection control throughout the survey and is to answer CEs of concern.
☐ One surveyor performs or coordinates the facility task to review for:
- Standard and transmission-based precautions
- Infection Prevention and Control Program (IPCP) standards, policies, and procedures
- Infection surveillance
- Water management
- Laundry services
- Antibiotic stewardship program (review at least one resident who is receiving an antibiotic if there are concerns)
- Infection Preventionist
- Influenza, pneumococcal, and COVID-19 immunizations
☐ Sample residents/staff as follows:
- Sample one staff to verify compliance with requirements for educating and offering COVID-19 immunization (select one staff from the actual working schedules for all staff provided during the entrance conference).
- Sample three residents on transmission-based precautions (TBP) for purposes of determining compliance with infection prevention and control national standards as well as resident care screening, testing, and reporting.
- Sample five residents for influenza, pneumococcal, and COVID-19 immunizations review.
General Standard Precautions:
☐ Staff are performing the following appropriately:
- Respiratory hygiene/cough etiquette
- Environmental cleaning and disinfection
- Reprocessing of reusable resident medical equipment (e.g., cleaning and disinfection of glucometers per device and disinfectant manufacturer’s instructions for use).
☐ Residents, visitors, and others at the facility wear appropriate source control in accordance with national standards.
☐ When there is a known communicable disease outbreak, the facility should screen visitors for signs and symptoms of the communicable disease in accordance with national standards and/or state and local health department recommendations. Screening may be conducted by active or passive (e.g., self-screening) means depending upon national, state, or local recommendations.
Hand Hygiene:
☐ Appropriate hand hygiene practices (i.e., alcohol-based hand rub (ABHR) or soap and water) are followed.
☐ Staff wash hands with soap and water when their hands are visibly soiled (e.g., blood, body fluids) or after caring for a resident with known or suspected C. difficile infection (CDI) or norovirus during an outbreak, or if endemic rates of CDI are high. ABHR is not appropriate to use under these circumstances.
☐ Staff perform hand hygiene (even if gloves are used) in the following situations:
- Before and after contact with the resident
- After contact with blood, body fluids, or visibly contaminated surfaces
- After contact with objects and surfaces in the resident’s environment
- After removing personal protective equipment (e.g., gloves, gown, eye protection, facemask)
- Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care)
☐ When being assisted by staff, resident hand hygiene is performed after toileting and before meals. How are residents reminded to perform hand hygiene?
☐ Interview appropriate staff to determine if hand hygiene supplies (e.g., ABHR, soap, paper towels) are readily available and who they contact for replacement supplies.
Personal Protective Equipment (PPE) Use For Standard Precautions:
☐ Determine if staff appropriately use and discard PPE including but not limited to the following:
- Gloves are worn if potential contact with blood or body fluid, mucous membranes, or non-intact skin
- Gloves are removed after contact with blood or body fluids, mucous membranes, or non-intact skin (and hand hygiene performed)
- Gloves are changed and hand hygiene is performed before moving from a contaminated body site to a clean body site during resident care
- An isolation gown is worn for direct resident contact if the resident has uncontained secretions or excretions (e.g., changing a resident and their linens when excretions would contaminate staff clothing)
- Appropriate mouth, nose, and eye protection (e.g., facemasks, goggles, face shield) along with isolation gowns are worn for resident care activities or procedures that are likely to contaminate mucous membranes or generate splashes or sprays of blood, body fluids, secretions, or excretions
- All staff are following appropriate source control (i.e., facemasks or respirators) in accordance with national standards
- PPE is appropriately discarded after resident care prior to leaving the room (except in the case of extended use of PPE per national and/or local recommendations) followed by hand hygiene
- If facilities are experiencing PPE shortages outside of their control, they are using PPE optimizing strategies in accordance with national standards
- Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (e.g., nursing units, therapy rooms)
☐ Interview appropriate staff to determine if PPE supplies are readily available, accessible, and used by staff and who they contact for replacement supplies.
Are there sufficient PPE supplies available to follow infection prevention and control guidelines? In the event of PPE shortages, what procedures is the facility taking to address this issue?
Enhanced Barrier Precautions (EBP):
EBP use is evaluated when investigating specific care activities such as wound care, enteral feeding, urinary catheter care, etc.
EBP are indicated during high-contact care activities for residents with infection or colonization with a CDC-targeted MDRO (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device.
High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing.
☐ Interview staff to determine if they are aware of which residents require the use of EBP prior to providing high-contact care activities?
☐ Is PPE readily available to staff?
Transmission-Based Precautions (TBP):
☐ Determine if appropriate transmission-based precautions are implemented including but not limited to:
- For a resident on contact precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment
- For a resident on droplet precautions: staff don a facemask and eye protection (goggles or face shield) within six feet of a resident and prior to resident room entry
- For a resident on airborne precautions: staff don a fit-tested N95 or higher-level respirator prior to room entry of a resident
- For a resident with an undiagnosed respiratory infection: staff follow standard, contact, and droplet precautions (i.e., facemask, gloves, isolation gown) with eye protection when caring for a resident unless the suspected diagnosis requires airborne precautions (e.g., tuberculosis)
- Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitor equipment) is used, or if not available, then reusable resident medical equipment is cleaned and disinfected according to manufacturers’ instructions using an EPA-registered disinfectant for healthcare settings and effective against the identified organism (if known) prior to use on another resident
- Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare settings and effective against the organism identified (if known) at least daily and when visibly soiled
- Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g., outside of a resident’s room, wing, or facility-wide)
- Residents on TBP are placed in a private/single room if available/appropriate or are cohorted with residents with the same pathogen or share a room with a roommate with limited risk factors in accordance with national standards
- Before visiting a resident who is on TBP or quarantine, the facility informs visitors of the potential risk of visiting and precautions necessary when visiting the resident
☐ Observe staff to determine if they use appropriate infection control precautions when moving between resident rooms, units, and other areas of the facility.
☐ Interview appropriate staff to determine if they are aware of processes/protocols for transmission-based precautions and how staff is monitored for compliance.
☐ If concerns are identified, expand the sample to include more residents on transmission-based precautions.
1. Did the staff use appropriate infection control practices (e.g., hand hygiene, use of PPE, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment)? ☐ Yes ☐ No F880
IPCP Standards Policies and Procedures:
☐ The facility established a facility-wide IPCP including written IPCP standards, policies, and procedures that are current and based on the facility assessment [according to §483.70(e)] and national standards (e.g., for undiagnosed respiratory illness and COVID-19).
☐ The facility’s policies or procedures include which communicable diseases are reportable to local and/or state public health authorities. The facility has a current list of reportable communicable diseases.
☐ Staff (e.g., infection preventionist) can identify and describe the communication protocol with local/state public health officials (e.g., to whom and when communicable diseases, healthcare-associated infections (as appropriate), and potential outbreaks must be reported).
☐ The policies and procedures are reviewed at least annually.
2. Does the facility have an IPCP including standards, policies, and procedures that are current, based on national standards, and reviewed at least annually? ☐ Yes ☐ No F880
Infection Surveillance:
☐ The facility prohibits employees with a communicable disease or infected skin lesions from direct contact with residents or their food if direct contact will transmit disease. Staff are excluded from work according to national standards.
☐ The facility has established/implemented a surveillance plan based on a facility assessment for identifying, tracking, monitoring, and/or reporting of infections, communicable diseases, and outbreaks among residents and staff. Interview staff and review the surveillance plan to determine how the staff monitors residents to identify possible infections and communicable diseases.
☐ The plan includes early detection, management of a potentially infectious symptomatic resident that requires laboratory testing, and/or the implementation of appropriate TBP/PPE (the plan may include tracking this information in an infectious disease log).
☐ The plan uses evidence-based surveillance criteria (e.g., CDC NHSN Long-Term Care or revised McGeer Criteria) to define infections and the use of a data collection tool.
☐ The plan includes ongoing analysis of surveillance data and documentation of follow-up activity in response.
☐ The facility has a process for communicating at time of transfer to an acute care hospital or other healthcare provider the diagnosis to include infection or multidrug-resistant organism colonization status, special instructions or precautions for ongoing care such as transmission-based precautions, medications [e.g., antibiotic(s)], laboratory and/or radiology test results, treatment, and discharge summary (if discharged).
☐ The facility has a process for obtaining pertinent notes such as discharge summary, lab results, current diagnoses, treatment, and infection or multidrug-resistant organism colonization status when residents are transferred back from acute care hospitals.
☐ Interview appropriate staff to determine if infection control concerns are identified, reported, and acted upon.
☐ The facility conducts testing of staff and residents for communicable diseases (e.g., COVID-19) in accordance with national standards.
☐ Based on observation or interview, the facility conducts specimen collection and testing in a manner consistent with standards of practice.
3. Did the facility provide appropriate infection surveillance? ☐ Yes ☐ No F880
Water Management:
Through interview (or record review as necessary) determine whether the facility has:
☐ Assessed (e.g., description of the building water systems using text and flow diagrams) where Legionella and other opportunistic waterborne pathogens can grow and spread;
☐ Measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency or EPA). For example, control measures can include visible inspections, disinfectant, temperature control (that may require mixing valves to prevent scalding);
☐ A way to monitor the measures they have in place (e.g., testing protocols, acceptable ranges) and established ways to intervene when control limits are not met; and
☐ Had a resident with legionellosis since the last recertification survey. Interview the infection preventionist (IP) to determine whether the facility has had a case(s). Interview the IP (and perform record review as necessary) to determine what actions the facility took in response to the identified case in the facility. The State Survey Agency should work with local/state public health authorities if possible to determine if the water management program was inadequate to prevent the growth of Legionella or other opportunistic waterborne pathogens and whether the facility implemented adequate prevention and control measures once the issue was identified.
4. Did the facility have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems? ☐ Yes ☐ No F880 ☐ N/A not a recertification survey
Laundry Services:
☐ Determine whether staff handle, store, and transport linens appropriately including but not limited to:
- Using standard precautions (e.g., gloves, gowns when sorting and rinsing) and minimal agitation for contaminated linen
- Holding contaminated linen and laundry bags away from his/her clothing/body during transport
- Bagging/containing contaminated linen where collected and sorted/rinsed only in the contaminated laundry area (double bagging of linen is only recommended if the outside of the bag is visibly contaminated or is observed to be wet on the outside of the bag)
- Transporting contaminated and clean linens in separate carts; if this is not possible, the contaminated linen cart should be thoroughly cleaned and disinfected per facility protocol before being used to move clean linens. Clean linens are transported by methods that ensure cleanliness e.g., protect from dust and soil
- If a laundry chute is in use, laundry bags are closed with no loose items
☐ Laundry Rooms – Determine whether staff:
- Maintain/use washing machines/dryers according to the manufacturer’s instructions for use
- If concerns, request evidence of maintenance log/record
- Use detergents, rinse aids/additives, and follow laundering directions according to the manufacturer’s instructions for use
5. Did the facility store, handle, transport, and process linens properly? ☐ Yes ☐ No F880 ☐ N/A not a recertification survey
Antibiotic Stewardship Program:
☐ Determine whether the facility has an antibiotic stewardship program that includes:
- Written antibiotic use protocols on antibiotic prescribing including the documentation of the indication, dosage, and duration of use of antibiotics
- Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics)
- A process for a periodic review of antibiotic use by prescribing practitioners: for example, review of laboratory and medication orders, progress notes, and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review, when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review as requested by the QAA committee
- Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic
- A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner
☐ If there are concerns with the antibiotic stewardship program, surveyors must complete an investigation utilizing the Unnecessary Medication Review CE Pathway for at least one resident on an antibiotic to assess whether the resident(s) is being prescribed an antibiotic unnecessarily. Expand the sample as needed to determine the scope and severity of findings.
Determine whether a resident is already included in the sample from the initial pool or as one of the five residents selected for the unnecessary medication review.
If there are not any sampled residents, select a high-risk resident receiving an antibiotic from the facility’s infection surveillance log (e.g., UTI without a culture, long-term use, no signs or symptoms noted) to add to the sample.
6. Did the facility conduct ongoing review for antibiotic stewardship? ☐ Yes ☐ No F881 ☐ N/A not a recertification survey
Infection Preventionist (IP):
During the interview with facility administration and Infection Preventionist(s), determine the following:
☐ The facility designated one or more individual(s) as the infection preventionist(s) who are responsible for the facility’s IPCP.
☐ The Infection Preventionist(s) works at least part-time at the facility.
☐ The Infection Preventionist(s) completed specialized training in infection prevention and control.
Review facility records for the following related to the designated IP:
☐ Professional training: the facility must provide documentation of the IP’s primary professional training. There must be one of the following:
- Certificate/diploma or degree in nursing; or
- Bachelor’s degree (or higher) in microbiology or epidemiology; or
- Associate’s degree or higher in medical technology or clinical laboratory science; or
- Completion of training in another related field such as that for physicians, pharmacists, and physician’s assistants
☐ Specialized training in infection prevention and control.
- Completed prior to assuming the role of the IP; and
- Evidence of completion is available (e.g., certificate)
7. Did the facility designate at least one qualified IP who is responsible for the facility’s IPCP? ☐ Yes ☐ No F882
Influenza, Pneumococcal, and COVID-19 Immunizations for Residents:
☐ Review the records of the five residents (influenza, pneumococcal, and COVID-19) for documentation of:
- Screening and eligibility to receive the vaccine(s)
- The provision of education related to the influenza, pneumococcal, and COVID-19 vaccines (such as the benefits and potential side effects)
- The administration of vaccines in accordance with national recommendations which includes doses administered. Facilities must follow the CDC and Advisory Committee on Immunization Practices (ACIP) recommendations for vaccines
- Allowing a resident or representative to accept or refuse the influenza, pneumococcal, and COVID-19 vaccines. If not provided, documentation as to why the vaccine(s) was not provided
☐ For surveys occurring during influenza season, unavailability of the influenza vaccine can be a valid reason why a facility has not implemented the influenza vaccine program, especially during the early weeks of the influenza season. Similarly, pneumococcal or COVID-19 vaccine supplies may be limited anytime of the year. Ask the facility to demonstrate that:
- The vaccine has been ordered and the facility received a confirmation of the order indicating that the vaccine has been shipped or that the product is not available but will be shipped when the supply is available
- Plans are developed on how and when the vaccines will be administered when they are available
☐ As necessary, determine if the facility developed influenza, pneumococcal, and COVID-19 vaccine policies and procedures for residents. Review policies and procedures and interview facility staff and residents and/or resident representatives to determine:
- How residents and/or resident representatives receive education on the benefits and potential side effects before being offered a vaccine. If multiple doses are required, how residents and/or resident representatives will again receive education on the benefits and potential side effects before being offered the vaccine
- How screening is conducted for eligibility (e.g., medical contraindications, previous vaccination), the vaccines are offered, and consent or refusal is obtained
8. Did the facility provide influenza and/or pneumococcal immunizations as required or appropriate for residents? ☐ Yes ☐ No F883
9. Did the facility educate and offer COVID-19 immunization as required or appropriate for residents? ☐ Yes ☐ No F887
Educate and Offer COVID-19 Immunizations for Staff:
☐ Review facility documentation for sampled staff for evidence of:
- Screening and eligibility to receive the vaccine(s)
- The provision of education regarding the benefits, risks, and potential side effects associated with the vaccine
- Being offered the vaccine or provided information on obtaining the vaccine
- The administration of vaccines if accepted in accordance with national recommendations
☐ As necessary, review facility policies and procedures and interview staff to determine:
- How staff are educated on the benefits, risks, and potential side effects before being offered a vaccine for each dose offered
- How staff vaccination status is documented
- How staff are screened for eligibility (e.g., medical contraindications, previous vaccination), vaccines offered, and consent is obtained
- If the facility provided information to staff on obtaining the vaccine if it is not available in the facility
10. Did the facility maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status? ☐ Yes ☐ No F887
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Infection Prevention Control & Immunizations
CMS-20054 (April 2024)