Infection Control

Description of Federal Requirements  [TOP]

The Federal regulation for Infection Control has 3 general provisions: a) that the facility establishing and maintain an infection control program; b) that they take steps to isolate residents when necessary to prevent the spread of infections; and c) they handle, store, process and transport linens in a way that prevents the spread of infections.  Further, the infection control program’s mission is specified as follows: to investigate, control, and prevent infections; to develop procedures for isolating individual residents who might spread infections.

The section on preventing infections mandates that the facility must isolate residents when the infection control program determines it is needed to prevent spread of infections; that the facility must prohibit employees with communicable diseases or infected skin lesions from direct contact with residents or their food “if direct contact will transmit the disease,” and that the facility must require staff to wash their hands after each direct resident contact “for which handwashing is indicated by acceptable professional practice.” 

Infection control is a relatively short Federal regulation with no additional detail, for example, on those establishing or directing the Infection Control program, the types of infection to be guarded against, acceptable forms of isolation, or details on how linens should be handled and stored.  Moreover, little related content is found in other regulations.  The regulation on Dietary Services, 483.35 (h), states, under provision (h) (2), that food must be prepared, distributed, and served under sanitary conditions, and, under provision (h) (3), that garbage and refuse must be disposed of “properly,” a general statement that would be related to odors and comfort and the development of disease in general, as well as the spread of infection.  Under the regulation on Physical Environment.483.70 (h), the word “sanitary” is included among the general adjectives for the kind of environment that should be maintained (along with “safe,” “functional,” and “comfortable”); in provision (h), (4), the facility must maintain an effective pest control program so that facility is free of pests and rodents, a provision that is presumably related to infection control.  The Federal regulation on Administration (483.75) contains no provisions on employee health to supplement the provisions in the Infection Control Regulation.

Comparison of State Requirements  [TOP]

Except for Vermont and West Virginia, which reiterate the federal regulation, all States have added additional content to the Federal requirements for infection control.  Sometimes the elaborations are brief, but most States have offered considerable detail.  Sometimes infection control stipulations are easily found because they are grouped together under that heading in a State’s regulations, and sometimes they are found scattered in various sections of State rules.  Quite often, a State has established rather elaborate rules for housekeeping and maintenance (which is not a distinct Federal regulation), and infection control rules are often found in such a section, often interspersed with other requirements for the safety of the environment.

The areas of the Federal regulation most often amplified by State regulations are: the nature, composition, or scope of the Infection Control Program that is required, including record-keeping; tuberculosis testing and other disease testing of employees and residents; reporting requirements; physical facilities and equipment related to infection control for functions such as handwashing, laundry, food preparation, cleaning, and garbage disposal; influenza and pneumonia immunization programs for residents over age 65; and staff orientation or education programs related to infection control.  In this general area, State Departments of Health often have established protocols and regulations related to reportable diseases and environmental safety; the State nursing home regulations typically cross-reference other State statutes and regulations of the Department of Health.  Federal guidelines and recommendations of the national Center for Disease Control (CDC) are also often cited or adopted as the State’s standards, especially regarding testing and treatments of employees and residents who have possible tuberculosis, the management of active tuberculosis, and immunization for influenza and pneumonia in nursing homes.   Some States repeat CDC material in their regulations and others simply cite the protocols. 

Health Screening of Employees and Residents  [TOP]

Alabama, Delaware, Indiana, New Jersey, Pennsylvania, Rhode Island, South Dakota, Texas, and Washington all have extensive sections on resident and employee health screening, especially tuberculosis (TB)  screening as well as procedures for treatment of latent and active TB.  Tuberculosis is the most frequently and elaborately addressed infectious disease for staff and residents (oddly, much more than HIV and AIDS), but typically lists of other reportable infectious diseases are included.  Delaware, for example, appends a list of 56 infectious diseases for which the facility must notify the health department if they occur within the facility, and in turn so that the Health Department in turn assesses the potential hazard and follows through accordingly. Pennsylvania offers considerable detail about how “significant outbreaks of nosocomial infections “as determined by the facility’s medical director” will be reported to the Division of Health Facilities field office, and also has a separate stipulation for reporting of scabies and lice to the same field offices.  New Jersey, which has particularly detailed protocols, requires health screening for all nursing home staff annually and that “the facility routinely offers Hepatitis B vaccine to all employees free of charge.”  Further illustrating from New Jersey, the State lays out mandatory employee health policies and procedures for infection control and sanitation by requiring that employees who have signs or symptoms of a communicable disease shall not be permitted to perform functions that expose residents to risk of transmission of the disease; and if a communicable disease prevents the employee from working a physician’s or advanced practice nurse’s statement approving the employee’s return shall be required. Prior to the employee’s return to work, the statements shall be reviewed by the administrator or the administrator’s designee. However, when an employee has been absent for no longer than three days, the employee’s return to work may be approved by either the facility’s DON or infection control committee, following assessment by a registered professional nurse. The facility shall develop and implement procedures for care of employees who become ill while at work or who have a work-related accident.

Immunization for Influenza and Pneumonia  [TOP]

Many States (e.g., Delaware, Maine, New Jersey, Rhode Island, South Dakota, Tennessee, Texas, and Washington) specify annual influenza and pneumonia immunizations for residents over age 65 or otherwise at risk, according to guidelines established by the CDC.  These rules vary somewhat as to the time periods for the influenza vaccine program, and whether expectations are identified for offering the vaccine to residents who are admitted during flu season but after the major program.  In Tennessee, for example, the program continues for newly admitted residents up to February first each year, whereas in South Dakota, the immunizations continue until April 1 each year.  In New Jersey, the initial immunizations must be complete by November 30, whereas other states offer more latitude. Almost invariably vaccines are not required if medically contraindicated, if the resident opposes them on religious grounds, or if the resident or resident’s guardian refuses the vaccine after the risks and benefits are described.  Considerable small variation is found in the details around this right to refuse and how it is recorded.  Rhode Island, which has extensive regulations for immunizations and records relating to them, also extends the specific right to refuse immunization to staff as well as residents. Washington specifies that the immunization program may either be on the site of the nursing home or an off site program.  [NHRegsComments:  CDC and CMS have a joint quality initiative around influenza and pneumonia immunization programs, immunization rates became a new national nursing home quality indicator in 2005, items have been added to the Minimum Data Set revision, MDS-3, and extensive training has been conducted for MDS coordinators on the topic.  Therefore, we would expect additional State regulatory language around these types of immunizations in the next several years.]

Infection Control Policies  [TOP]

Infection control programs are sometimes vested in a single-purpose committee with established membership, and sometimes established as a subset of some other committee related to quality of care.  Ordinarily, representation includes the medical director, nursing, pharmacy, and housekeeping.  The frequency of meeting for the relevant committees varies from annually to quarterly, as do reviews and incident reporting.  Several of the States require analyses of disease clusters in the facility.  Mandatory orientations and in-service training with varying frequency are often built into the program, sometimes for all departments and sometimes for categories of personnel.   Some other examples are described below.  As is seen in these examples, especially for Colorado, the specification of the structure can be interspersed with elaborate detail on infection control activities.  [NHRegsComments. It appears that some of the more clearly specified programs confer clear authority on the infection control program to take steps related to admissions, discharges, and care routines that would over-ride ordinary hierarchical lines of authority in the nursing home.]

4New Jersey, already cited for detail around employee health programs, has perhaps the most extensive system of credentials for the infection control program.  An infection control coordinator must be appointed who is certified in Infection Control (CIC) by the National Board of Infection Control, P.O. Box 14661, Lenexa, KS 66286-4661. The coordinator must also be an active member of the National Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), and must have received at least 25 hours of training in infection control, and receives an additional six hours of training annually.  Others of the infection control advisory program are also expected to be trained for their responsibilities. 

4In Minnesota, the nursing home must assign to one person, either a physician or a registered nurse, the responsibility of directing the infection control program.

4Connecticut has an extensive section on developing an infection prevention, surveillance and control program that includes: authority governing structure and function of program; membership of committee; committee function; chairman of committee shall be a physician or health care professional qualified by education or experience; coordinator of program; meeting specifications; education and in-service requirements; records; responsibilities of committee and laundry requirements. 

4Colorado has extensive infection control procedures. Written policies must include: a policy prohibiting admission of residents who have a communicable disease with a significant risk of transmission; a policy for preventing transmission of disease and policy of reporting diseases to local health officials. Residents who have a communicable infection that is primarily transmitted either sexually or by blood products may be admitted to facilities upon order of a physician and the following precautions must be addressed: hand-washing; handling of sharp objects; washing of linens in water with at least 140 degree temperature; use of disposable gloves; equipment shall be immediately at hand to minimize need for mouth-to-mouth resuscitation; disinfecting contaminated area following spills of blood or bodily fluid; disposal of infective waste procedures; a private room is indicated if resident’s hygiene is poor (in general, residents infected with the same organism may share a room, eat and participate in activities together); and health care workers with colds or other communicable diseases shall not be assigned to care for residents who are highly vulnerable to infection. [NHRegsComment:  This allusion to giving the scarce commodity of a single room to resident’s whose general hygiene is poor is a curious, as opposed to isolating in a single room for residents with infectious diseases, is a curious provision.  One wonders whether staff could not more directly address general poor hygiene, and the perverse incentive this policy contains to get a single room in facilities where they are in scarce supply.]  Hand-washing techniques include: remove watches and rings, and roll sleeves of clothing above elbows; wash hands and forearms with soap or detergent with friction, not a brush, and rinse under running water; repeat the washing procedure two or three times and dry hands with a disposable towel. If facility allows pets they shall be vaccinated and licensed as appropriate. 

4 In Oklahoma, the purview of the infection control program are laid out in great detail.  The scope extends top traffic control in high-risk areas, and visiting rules for high-risk residents. The facility shall maintain a sanitary environment and prevent the development and transmission of infection in the following areas.

(1)    Food handling practices.
(2)    Laundry practices including linen handling.
(3)    Disposal of environmental and resident wastes.
(4)    Pest control measures.
(5)    Traffic control for high-risk areas.
(6)    Visiting rules for high-risk residents.
(7)    Sources of air-borne infections.
(8)    Health status of all employees and residents.
(9)    Isolation area for residents with communicable diseases.
(c)    Infection control policies to break the transmission of infection shall include the following:
(1)    Excluding personnel and visitors with communicable infections.
(2)    Limiting traffic in dietary and medication rooms.
(3)    Using aseptic and isolation techniques including hand washing techniques.
(4)    Bagging each resident's trash and refuse.
(5)    Issuing daily damp wipe cloths, treated dust cloths and clean wet mops, as needed.
(6)    Laundering the used wet mops and cleaning cloths every day.
(7)    Cleaning the equipment for resident use daily, and the storage and housekeeping closets as needed.
(8)    Providing properly identifiable plastic bags for the proper disposal of infected materials.
(d)    When scheduled to be cleaned, the toilet areas, utility rooms, and work closets, shall be cleaned with a disinfectant solution and fresh air shall be introduced to deodorize.
[Source: Added at 9 Ok Reg 3163, eff 7-1-92 (emergency); Added at 10 Ok Reg 1639, eff 6-1-93]

4California stipulates that patients with infectious diseases requiring that patients with infectious diseases not be admitted to facility or cared for unless the following requirements are met: patient must be accommodated in a room that is vented to the outside, provided with a separate toilet, hand-washing facility, soap dispenser and individual towels. Also required are: separate provisions for handling contaminated linens and dishes; written infection control policies and procedures; procedures and policies be available at each nurse’s station along with the name, address and telephone numbers of local health officers.

Infectious Control Programs and Facilities  [TOP]

As already suggested, it is difficult to separate the structure of an infection control program from the required activities and procedures.  In turn the required procedures are often inextricable from required facilities or equipment.  Procedures particularly concern handwashing and isolation. Environmental specifications may relate to sinks for both food preparation and lavatories, laundry sorting and storage rooms, and ventilation and screening.  Some States have specifications around ventilation in isolation rooms, and several have specifications for changing water in humidifiers and solutions in nebulizers to guard against air-borne infections.   Specifications about equipment can extend to towels, and dishes and utensils,   Specifications for staff include provisions for gloves, gowns, and hairnets at various times.  [NHRegsComments.  As nursing homes move towards more normalized and smaller residential environments with residential kitchens, laundry areas, and individual resident full bathrooms, it may be necessary to revisit some of the specifications related to facilities and cross-contamination.  Provisions that prohibit using the same sink to wash hands and to rinse any dishes or foods, prohibitions against soiled towels remaining in a resident’s bathroom (with no particular definition about what amount of use constitutes ‘soiling,” and many other details concerning waste receptacles, sinks, food handling and the like may, if inflexibly interpreted, may erect unnecessary barriers to normal life.  Also some rules may lead facilities to over-use of paper, plastic and other disposable products, or prohibit the sensible inclusion of a resident’s own hand towels in her personal wash.  Some facilities where some meals are provided on a short-order basis may be unclear about when staff members need to don unsightly gloves to bring food to residents.  Many of the rules seem to have been developed with the idea in mind of large institutional kitchens, laundries, and housekeeping areas. It is possible that greater and more widespread training about the principles of cross-contamination and individual problem-solving will come to replace rigid environmental rules. Similarly some provisos around appliances such as dishwashers, washers and dryers, stoves, cleaning equipment, and the like may need to be revised for a situation where residents have their own broom closets and bathrooms, and small groups of residents have their own kitchens and laundries. ]

4In Ohio, hand-washing techniques include: washing hands vigorously with soap and water for at least ten to fifteen seconds or, if hand-washing facilities are not readily available, with water-less alcohol-based product used according to manufacturer’s directions or other alternative methods accepted by the Centers for Disease Control and Prevention; and after using toilet; before direct contact with a resident; immediately after touching body substances; after handling potentially contaminated objects; between direct contact with different residents and after removing gloves.

4Hawaii’s provisions for isolating patients with infectious diseases until appropriate transfer can be made include: written policy which outlines proper isolation and infection control techniques; at least one single bedroom designated as an isolation room; an adjoining toilet room with nurses’ call system, a lavatory, and a toilet; lavatory shall be provided with controls not requiring direct contact of the hands for operation; methods for cleaning and disposing contaminated materials; provision in isolation room for visual observation of patient by means of the view window located in door or walls of room or by an approved mechanical system, i.e., closed circuit television monitoring.

4Oregon  requires that nursing personnel shall not be simultaneously responsible for duties which are incompatible with sanitation. This explicitly includes prohibiting personnel from being assigned to both resident care and work in the kitchen, laundry, or housekeeping. This also prohibits personnel from having responsibility for work in the kitchen combined with laundry, housekeeping or other such conflicting tasks.

4In Wyoming full-time or part-time members of the nursing staff shall be primarily engaged in pro­viding nursing services and only in rare and exceptional circumstances shall be involved in food preparation, housekeeping, laundry or maintenance services. Proper infection control procedures shall be adhered to at all times.

[NHRegsComment:  The Oregon and Wyoming language cited above, and similar language in other States may conflict with some of the goals of culture change.  As nursing homes move to smaller neighborhood configurations, and as they create more “normal” living environments, nursing staff are often assuming broader roles that combine personal care with cooking, food service, light housekeeping, and laundry.  Sometimes called “universal worker” policies, these roles by definition mean that staff members in contact with food and laundry are not completely isolated from residents. Proponents of universal worker policies cite advantages, including a higher quality of relationship among residents and care staff who spend more time together in daily pursuits.  The challenge will be to develop workable infection control policies that are compatible with these culture changes.  It is obviously easier to enforce policies against cross-contamination by strict separation of roles of various departments, but such separations are increasingly incompatible with some current directions in nursing homes. Note, too, that some provisions requiring that nursing tasks not be interspersed with housekeeping, dietary, and laundry tasks are aimed, not especially at infection control, but rather on ensuring a sufficient complement of staff to perform nursing duties.  It may become necessary to disentangle the various reasons behind prohibitions against direct care staff performing certain other functions in order to facilitate “universal workers.”]

  4Kansas has extensive procedures for linens and resident clothing. Facility shall handle soiled linen and soiled resident clothing as little as possible and with minimum agitation to prevent gross microbial contamination of air and of persons handling the items; all soiled linen and resident clothing shall be placed in bags or in carts immediately at the location where they were used and shall not sort and pre-rinse linen and resident clothing in resident-care areas; linens and clothing soiled with blood or body fluids shall be deposited and transported in bags that prevent leakage; linens shall be washed with detergent in water of at least 160 degrees F. If facility chooses to wash linens and soiled resident clothing in water at less than 160 degrees F the following conditions must be met: temperature sensors and gauges capable of monitoring water temperatures to ensure that the wash water does not fall below 72 degree F are installed on each washing machine; the chemicals used for low temperature washing emulsify in 70 degrees water; the supplier of the chemical specifies low-temperature wash; charts providing specific information concerning the formulas to be used are posted; the facility ensure that laundry staff receives in-service training by the chemical supplier and the maintenance staff monitors chemical usage and wash water temperatures at least daily to ensure conformance with the chemical supplier’s instructions.

 4Washington requires safe and effective procedures for disinfecting all bathing and therapy tubs between each resident use and swimming pools, spas and hot tubs.

4New Hampshire requires that all garbage refuse shall be stored in covered receptacles until disposed of in accordance with the town or city requirements for garbage disposal; in-house garbage receptacles shall be kept covered except when the lid is removed for temporary use, be durable, insect and rodent proof and water tight and lined or cleaned with soap and water and disinfected after each emptying and trash receptacles for paper waste may be kept uncovered in all areas except dietary areas.

4New Jersey requires that garbage compactors shall be located on an impervious pad that is graded to a drain. For new construction, the drain shall be connected to the sanitary sewage disposal system.

[NHRegsPlus Comments.  Some of the detailed regulations on cleaning solutions, disinfectants, and handwashing solutions, including those that require each facility to develop an approved list of products, may interfere with individual choice of toiletries, cosmetics, and household goods.  Some of these requirements may be related to infection control and some to Occupational Health standards so that staff members can be aware of ingredients of the products they use and avoid allergies, but in either case there is a potential for the rules to negatively affect resident autonomy and choice.]

Precautions Related to Dead Bodies  [TOP]

4New York includes a Notice to Funeral Director in its regulations. If, at time of death, a resident was diagnosed as having a specific communicable disease, a written report of such disease shall accompany the body when it is released to the funeral director or his or her agent, except that not HIV-related information shall be disclosed to the funeral director unless the funeral director has access in the ordinary course of business to HIV-related information on the death certificate of the deceased individual.  In Kansas, before the removal of a deceased resident from the facility, the funeral director or the person transporting the body shall be notified by facility staff of any particular precautions that the facility followed related to transmission of communicable diseases.

[Summarized: September, 2006]
 

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State regulation on Infection Control at the bottom of the Table.