VHCA-VCAL staff has learned that one of the 10 national Infection Control Pilot Surveys occurred this month in Virginia.  Thanks to the facility, we were able to obtain the information used by the CMS-contracted surveyors for this pilot.  While we will not know until this fall at the earliest, we suspect that much of what the Centers for Medicare and Medicaid Services (CMS) focused on in this survey will eventually end up in the State Operations Manual (SOM).

Thus far in 2016, a SMART analysis indicates that citations for F441 – Infection Control are the third most frequently cited deficiency: Reasons for citation include:  break in infection control practices during medication administration, handwashing, infection control tracking, point of care devices (e.g., blood glucose monitors, etc.).

VHCA-VCAL associate member Mary Chiles of Chiles Healthcare Consulting advises that centers should prepare for the increased focus on infection control by reviewing their center’s approach to the following:

• Infection Prevention Policies
• Quality Assessment and Assurance (QAA) Plan
• Evidence that the facility can show the survey team that the facility’s infection control concerns have been brought up through and to its QAA committee
• Hand hygiene policies  for staff and residents
• Hand hygiene surveillance and rates
• Medication administration policy
• Point of care testing policies and audits on adherence to policy
• Central venous catheter policy
• Urinary catheter policy
• Cleaning and disinfection policy and audits
• Reusable medical device and/or equipment policy
• Food handling policy
• Employee health policies including work-exclusion, reporting illness to supervisors, health screening for food handlers, Influenza
• Influenza and pneumococcal vaccination policy
• Outbreak policy and plan
• Tuberculosis screening policy for residents and employees

Additionally, it appears that residents with the following characteristics may be of focus when reviewing infection control practices:

• New/worsened pressure ulcers (stage 2-4}
• Wound care/dressing changes
• Urinary tract infection
• Indwelling urinary catheter dialysis
• Recent Admittance/Transfer/Discharge/Hospitalization
• Significant change in status
• Specialty Care (central lines/central venous catheters with infusions, ventilators/ residents dependent upon ventilators, oxygen, tracheostomies)
• Respiratory therapy treatments  (i.e., nebulizer/aerosol)
• Dehydration
• Infections
• Isolation precautions (contact, droplet, airborne)
• Intravenous fluids
• Diabetes-blood glucose monitoring-injections
• Antibiotics
• Injections