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2015 FUNDAMENTALSOCTOBER 21 - 23, 2015
ROXANNE PERRY, RN, MSMANAGER
INTEGRATED PROGRAMS MANAGEMENT SECTION
Regulations for an Infection Prevention and
Control Program
Michigan Department of Health and Human Services
Medical Services Administration
Bureau of Medicaid Policy and Health System Innovation
Integrated Care Division
Integrated Programs Management Section
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Objectives
List at least 3 purposes for developing an effective infection prevention and control program.
List and describe Federal and State Infection Prevention & Control Regulations for different types of health care facilities.
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Historical Events 306-337 AD: Constantine the Great 1843: Oliver Wendell Holmes
1846: Ignaz Semmelweis
1860: Louis Pasteur 1867: Joseph Lister
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Historical Events
1800’s: Florence Nightingale
1837 – Committed herself to nursing
1845 – Entered nursing – cared for poor/indigent population
1851 – Official training/nursing career
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Historical Events
1854 – Crimean War – cleaned hospital equipment and reorganized patient care
1855 – Concluded that hospital deaths were due to poor living conditions
1950’s: Staphylococcal era 1959: First Infection Control Nurse
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Historical Events Change from Universal Precautions to Standard
Precautions
Isolation Practices – least restrictive
Hepatitis B Vaccine
HIV/AIDS
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Historical Events
MSIPC from MSIC
Influenza Vaccine
Pneumococcal Vaccine
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Why have an Infection Prevention & Control Program? Prevent and protect residents, employees,
volunteers & visitors from infections
Maximize quality of care
Avoid legal issues
Avoid adverse publicity
Comply with regulations and accreditation
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Regulations/Guidelines for the Prevention & Control of Infections
Federal GovernmentCenters for Medicare and Medicaid
Services (CMS)
Center for Disease Control (CDC)
Occupational Safety and Health Administration (OSHA)
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Regulations/Guidelines for the Prevention & Control of Infections State Government
Michigan Public Health Code
Licensing Rules
Communicable Disease Rules
Medical Waste Regulatory Program
MIOSHA
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Regulations/Guidelines for the Prevention & Control of Infections
Accreditation Entities
Association for Professionals in Infection Control and Epidemiology
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Federal and State RegulationsDepartment of Licensing and Regulatory Affairs
Bureau of Community and Health Services
Long Term Care – State and Federal
ICF/MR - Federal
Acute Care – State and Federal
CLIA Laboratories – State/Federal
Federal and State Regulations
Home Health – Federal
Ambulatory Surgical Clinics(ASC)/Freestanding Surgical Outpatient Facilities(FSOF) – State and Federal
End Stage Renal Disease - Federal
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Federal and State Regulations
Outpatient Physical/Speech Therapy Centers- Federal
Rural Health Clinics – Federal
Critical Access Hospitals – State and Federal
Comprehensive Outpatient Rehab Facilities - Federal
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Federal and State Regulations
Portable X-Ray Units – Federal
Hospice Residences – State and Federal
Hospice Agencies– State and Federal
Psychiatric Hospitals- State and Federal
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Long Term Care Infection Prevention/Control
Federal Regulations
Long Term Care Infection Prevention/Control
F441§483.65 Infection ControlThe facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.
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Long Term Care Infection Prevention/Control
F441 continued
§483.65(a) Infection Control Program
§483.65(b) Preventing Spread of Infection
§483.65(c) Linens
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Long Term Care Infection Prevention/Control
F334§483.25(n) Influenza and pneumococcal immunizations---(1) Influenza. The facility must develop policies and procedures that ensure that—(2) Pneumococcal disease. The facility must develop policies and procedures that ensure that—
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Long Term Care Infection Prevention/Control
F281
483.20(k)(3)
The services provided or arranged by the facility must—
(i) Meet professional standards of quality...
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Long Term Care Infection Prevention/Control
F520483.75(o) Quality Assessment and Assurance
(1) A facility must maintain a quality assessment and assurance committee consisting of-(i) The director of nursing services;(ii) A physician designated by the facility;
And(iii) At least 3 other members of the facility’s staff.
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Long Term Care Infection Prevention/Control
F520 continued(2) The quality assessment and assurance committee-(3) State or the Secretary may not require disclosure of
the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
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Long Term Care Infection Prevention/Control
F520 continued
Summary Identifies quality issues Establishes protocols Develops and implements corrective
actions Evaluate response
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Long Term Care Infection Prevention/Control
Michigan Licensure Regulations
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Michigan Licensure RegulationRule 507
R 325.20507 Infection Control A written policy shall govern the control of
communicable disease and infections in the nursing home and shall require the establishment and operation of an Infection Control Committee, which shall include at least the director of nursing and representatives of administration, dietary, housekeeping, and maintenance services.
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Michigan Licensure RegulationRule 402
R 325.20402Health of Employees and Others Providing Care
An employee on duty in the home shall be in good health and free from communicable disease.
An employee shall have an intradermal test for tuberculosis at the beginning of employment and annually thereafter. If at any time the skin test is positive, the local health department shall be notified and the employee shall have a chest x-ray to determine the presence of disease.
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Michigan Licensure RegulationRule 506
R 325.20506 Tuberculosis Testing
The facility shall develop and implement policies governing the periodic intradermal tuberculin testing of patients in addition to the requirement for a chest x-ray on admission.
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Hospital Infection Prevention/Control
Federal Regulations
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Hospital Infection Prevention/Control
A-0747
482.42 Condition of Participation: Infection Control
The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.
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Hospital Infection Prevention/Control
A-0748
482.42(a) Standard: Organization and Policies
A person or persons must be designated as infection control officers to develop and implement policies governing control of infections and communicable diseases….
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Hospital Infection Prevention/Control
A-0748
482.42(a)(1) The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.
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Hospital Infection Prevention/Control
A-0749
482.42(a)…. The infection control officer or officers must maintain a log of incidents related to infections and communicable diseases.
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Hospital Infection Control
A-0756
482.42(b) Standard: Responsibilities of Chief Executive Officer, Medical Staff, and Director of Nursing Services
The chief executive officer, the medical staff, and the director of nursing must—
Hospital Infection Control
(1) Ensure that the hospital-wide quality assessment and performance improvement (QAPI) program and training programs address problems identified by the infection control officer or officers; and
(2) Be responsible for the implementation of successful corrective action plans in affected problem areas.
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Hospital Infection Prevention/Control
Michigan Licensure Regulations
(Minimum Standards for Hospitals)
Hospital Infection Prevention/Control
R 325.1021 (Rule 21)
Compliance with law and regulations
R 325.1022 (Rule 22)
Water and ice supply
R 325.1023 (Rule 23)
Sewage, garbage, and waste disposal
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Hospital Infection Prevention/Control
R 325.1024 (Rule 24)
Laundering and sterilization of linens; Sterilization of instruments and utensils
R 325.1025 (Rule 25)
Heating and ventilating
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Hospital Infection Prevention/Control
R 325.1026 (Rule 26) General maintenance.
R 325.1027 (Rule 27)
Patient Care.
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Infection Control ReferencesFederal Regulations
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_Appendixtoc.pdf
State Regulationshttp://www.michigan.gov/lara/0,4601,7-154-63294---,00.html
MSIPChttp://www.msipc.org/
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