5 Steps to Infection Prevention & Control Plan (IPCP) Compliance

July 12, 2024

 

Nursing homes must maintain an infection prevention and control program (IPCP) to provide a safe and sanitary environment for residents while preventing the transmission of communicable diseases and infections. With F880 continually among the top citations in 2024, here are five key areas to
focus on to comply with the requirements.

 

STEP 1: IPCP

• Establish 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).
• Ensure your policies or procedures include which communicable diseases are reportable to local and/or state public health authorities.
• Train staff (e.g., infection preventionist) to 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).
• Review the policies and procedures at least annually.

 

STEP 2: INFECTION SURVEILLANCE

• Establish policies and procedures that prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.
• Establish/implement 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. Practice interviewing staff and review the surveillance plan with them to ensure they know how to monitor residents to identify possible infections and communicable diseases.

 

STEP 3: WATER MANAGEMENT

• Conduct an assessment (e.g., description of the building water systems using text and flow diagrams) to determine where Legionella and other opportunistic waterborne pathogens can grow and spread.
• Implement 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, and temperature control (that may require mixing valves to prevent scalding).
• Create a way to monitor the measures you have in place (e.g., testing protocols, acceptable ranges), and establish how to intervene when control limits are not met.
• Continually monitor your infection prevention log for residents with legionellosis. Compare any cases found with the audits done in your water management plan to see if there is a connection between an unmet control measure and the infection. Ensure all appropriate steps were taken to react to the unmet control measure.

 

STEP 4: INFECTION PREVENTION LOG

• Review your infection prevention log on a daily basis. Look for similar symptoms and infections that might indicate transmission between staff and residents or residents to residents.
• Be sure to indicate what actions were taken for each infection such as precautions, antibiotics, etc.
• Look for similar pathogens and how they spread in the facility by doing some kind of tracing or mapping.

 

STEP 5: LAUNDRY SERVICES

• Ensure your 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 their clothing/body during transport
  • Bagging/containing contaminated linen where collected, and sorting/rinsing 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 should be 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

 

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