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Fundamentals of CMS Updates to Appendix PP of the State Operations Manual: Infection Control

F880: Infection Prevention and Control

The regulation governing the F880 tag requires that facilities develop and implement ongoing infection control and prevention programs and written policies and procedures for infection control to prevent, recognize, and control the onset and spread of infection, to the extent possible, and guide staff in following proper precautions. Noncompliance at F880 will be cited if infection control and prevention program, policies, and procedures are not established, updated, and followed. Noncompliance will also be cited if the facility does not maintain a system for recording identified infection control incidents and taking appropriate corrective actions.

SOM Revisions Increase Focus on Specific Organisms

The SOM revisions expand the discussion of specific organisms, the control of which should be priorities for infection preventionists, to include C. difficile, Legionellosis, and multi-drug-resistant organisms (MDROs). The guidance emphasizes the importance of the proper use of appropriate personal protective equipment in maintaining contact precautions to prevent the transmission of pathogens that are spread by direct or indirect contact with the resident or environment, such as C. difficile. Contact precautions are also recommended when caring for residents infected or colonized with MDROs. The guidance further directs surveyors to review a facility's written infection prevention policies and documentation of a facility's water management program, as well as the facility's efforts to minimize the risk of Legionella.

Key Takeaways

The new SOM guidance directs surveyors to seek confirmation that the facility has taken measures to control organisms such as C. difficile, Legionellosis, and MDROs that have long been clinical concerns, but for which specific guidance on the definition of noncompliance regarding prevention and control has not been substantial. Facilities must develop and implement written policies defining standard precautions, transmission-based precautions, and environmental cleaning and disinfection practices. Facilities must also be prepared to demonstrate measures taken to minimize the risk of Legionella in building water systems by having a documented water management program.

F882: Infection Preventionist Qualifications/Role

The intent of the regulations governing F882 is to ensure that each facility designates a qualified individual or individuals to be responsible for implementing programs and activities to prevent and control infections. Noncompliance at this tag will be cited if there is no specified individual tasked as responsible for the facility's infection control efforts, or if the individual deemed responsible is not professionally trained, including specialized training in infection prevention and control; is not qualified; and does not work a minimum number of hours per week as a designated infection preventionist.

SOM Guidance for F882 Has Been Completely Updated

F882 is now governed by newly rewritten guidance that mandates professional and specialized training for infection preventionists, who are responsible for all aspects of a facility's infection prevention and control program, including the facility's Antibiotic Stewardship Program. The infection preventionist must be professionally trained in nursing, medical technology, microbiology, epidemiology, or another related field. Specialized training may include care for residents with invasive medical devices, handling resident care equipment, and treatments such as dialysis and other high-acuity conditions.

Facilities must designate at least one, and may designate more than one, individual to obtain this training and fulfill these duties. The guidance clarifies that the infection preventionist must work at least part-time, as determined by the facility assessment, and must work physically onsite at the facility – the infection preventionist cannot be an offsite consultant or perform the infection preventionist's work at a separate location.

Key Takeaways

The new guidance indicates that CMS has concerns regarding the pressures that the COVID-19 pandemic and the possibility of other pandemics have placed on facility infection preventionists. The revisions appear to be designed to ensure that each infection preventionist not only has the education and training to perform competently but is also equipped with appropriate resources and support.

For specific guidance or more information about this alert, please contact Howard Sollins, Stefanie Doyle, or any other member of Baker Donelson's Long Term Care Team.

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