Navigating Challenging Compliance Waters Bonnie Cruz, RN, MSN, Med

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1 Opening Remarks Bonnie Cruz, RN, MSN, M Ed NADONA 2010 Today s Session Objectives Recall the important changes and revisions on F-Tag 441 Review the implications of F-Tag 441 revisions on hand hygiene and infection control practices Recognize the CDC s role (directives and recommendations) in fostering compliance with CMS guidelines Utilize infection prevention tools and best practices for improved resident outcomes and ensure regulatory compliance Utilize the value of using an epidemiological definition Identify the disadvantage of calculating a total infection rate Describe how using technology can assist with identifying a potential problem Today s Agenda Welcome and Opening Remarks Knowing the Ropes A Review of F-Tag 441 Charting the Course Managing a State Survey with Confidence Full Speed Ahead Surveillance for Successful Outcomes Closing Remarks All Hands on Deck 10 mins 30 mins 30 mins 35 mins 15mins 3 1

2 Today s Presenters Bonnie Cruz, RN, MSN, M Ed Manor at Blue Water Bay Niceville, Florida Norma Geraldine Jerri Way, RN, CDONA Regional Nurse Consultant Stonegate Senior Care Fort Worth, Texas Steven J. Schweon, RN, MPH, MSN, CIC, HEM Infection Preventionist Pleasant Valley Manor Nursing Home Stroudsburg, Pennsylvania 4 Historical Review of Hand Hygiene in LTC Infections are the third cause of death in healthcare settings Many regulations enforce hand hygiene guidelines specified by CMS, CDC, APIC, JCAHO Monies for research for DON and leadership in LTC were and remain very limited LTC does lacks the funding that acute care receive Historical Review of Hand Hygiene in LTC (cont.) LTC DONs understand the importance of clean hands. Recognition of the role of new microorganism in infections HH has become more important in LTC Hand hygiene programs benefit greatly from availability of information from the internet CMS guidance and QIS for state surveyors now keep hand-washing and hand hygiene into focus. 2

3 Historical Review of Hand Hygiene in LTC (cont.) Yet we still fail to fully appreciate the true impact and repercussions of poor hand hygiene. 7 The Infection Chain Reaction Begins 8 The Infection Chain Reaction Continues 9 3

4 B ut time or resources are insufficient Mo re infe ction s sp re ad Need to invest time and effort into curbing infections to minimize the downstream cost of handlin g infect ions The Infection Chain Reaction Recap Infections drive EVERYTHING 100 Events 10 Why Hand Hygiene Matters? Infections are a major cause of death in health care settings. - Unclean staff hands - Unclean resident hands Infections affect many areas - Resident well-being - Staff turnover and resident turnover - Admissions from and to hospitals - Bottom line Cause state inspections - Ombudsman visits - OSHA visits A Treacherous Cycle More infections spread Need to invest time and effort into curbing infections to minimize the downstream cost of handling infections But time or resources are insufficient But time or resources are insufficient But time or resources are insufficient Need to invest time and effort into curbing infections to minimize the downstream cost of handling infections More infections spread Need to invest time and effort into curbing infections to minimize the downstream cost of handling infections More infections spread 12 4

5 Unity: Working together for a better future. For a better reach Elevating hand hygiene Knowing the Ropes Without Hanging Yourself Bonnie Cruz, RN, MSN, M Ed NADONA 2010 Section Objectives and Goals Brief review of current CMS guidance with respect to infection control and HH Highlight the increased importance of infection control under the new CMS QIS reporting for infection control What are implications for LTC centers? Challenges in balancing infection control with a homelike setting Can CDC and CMS guidelines effectively coexist? Reconciling infection control practices to often-changing guidance and conflicting regulations 5

6 Awareness and Practice An awareness of maintaining good infection control in LTCFs was not necessarily translated into sustained infection control practices Overburdened DON Unable to implement all good practices for robust infection control Potential for lapses and increased HAIs 16 Good Practice is Not Optional Current CMS guidance brings infection control to the forefront, and LTCFs have to be compliant Overburdened DON Eradication of HAIs Same situation Has to implement all practices to remain compliant with infection control guidelines Expectation of different results Incidence of Healthcare-Acquired Infections (HAIs) Urinary tract infections, pneumonia, and skin and soft-tissue infections account for 75% of the identified infections in nursing homes. R. Monina Klevens, Jonathan R. Edwards, Chesley L. Richards, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports 2007;122:

7 High Cost of Treating HAIs Lab tests Antibiotics Hospitalization Physician visit Between $673 million and $2 billion Strausbaugh LJ, Joseph CL. The burden of infection in long-term care. Infect Control Hosp Epidemiol 2000;21: Current CMS Guidance Mandates Infection Control Practices to Prevent HAIs No room \ for error! 20 Overview of CMS Guidance: Infection Control and HH 21 7

8 CMS in 2009 On, Dec. 2, 2009, CMS issued Transmittal 55, the final version of the Interpretive Guidance for F441 Interpretive Guidance for F441 directs surveyors to focus on infection prevention and control and on sanitary practices in all departments Infection Control Regulations Long-term care federal regulations at Tag 441 state the following: Infection Control The facility must establish and maintain an Infection Control Program designed to provide a safe and comfortable environment and to help prevent the development and transmission of disease and infection. Infection Control Program Key Points The facility must establish an Infection Control Program under which it accomplishes the following: 1. Investigates, controls, and prevents infections in the facility 2. Decides what procedures, such as isolation, should be applied to an individual resident 3. Maintains a record of incidents and corrective actions related to infections 8

9 Preventing Spread of Infection Key Points 1. When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident 2. The facility must 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 3. The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice Preventing Spread of Infection Key Points Linens Personnel must handle, store, process, and transport linens so as to prevent the spread of infection LTC Centers Will Be Accountable During each recertification survey, and other surveys when indicated, the survey team will take the following steps: Review the facility s record of incidents of infection and related corrective actions to help determine whether the facility is identifying, recording, and analyzing infections Review all of the facility s infection control policies and procedures (e.g., nursing, dietary, rehabilitation, housekeeping, environment, laundry, etc) 27 9

10 LTC Centers Will Be Accountable (cont.) During each recertification survey, and other surveys when indicated, the survey team will take the following steps: Observe various disciplines (nursing, dietary, housekeeping, etc) to determine if staff members follow appropriate infection control practices and transmissionbased precautionary procedures Interviewthe resident, family, or responsible party to identify whether they have received education and information about infection control practices, such as appropriate hand hygiene and any special precautions applicable to the resident LTC Centers Will Be Accountable (cont.) During each recertification survey, and other surveys when indicated, the survey team will take the following steps: Interview direct care staff Review records of sampled residents Review employees records to determine if they receive initial and ongoing employee infection control training regarding critical elements of the infection control plan Review the facility s evaluation of the appropriateness and effectiveness of antibiotics for residents who are identified as receiving antibiotics Situations That Require Hand Washing Under CMS Guidance After contact with a resident with infectious diarrhea, and infections caused by Norovirus, salmonella, shigella, and C. difficile Visibly soiled Before & after eye drops Personal or resident toileting and after personal hygiene Before and after eating/handling food 30 10

11 Practical Implications of CMS Regulations for LTCFs LTC centers have to perform the following tasks: Educate staff Become practice compliant Implement an infection control program Increase vigilance toward HH observance Assess how to address increased implementation costs without additional funding Practical Implications of CMS Regulations for LTCFs (cont.) Equipment care E.g., blood glucose meter device handling Alcohol is not an approved product for cleaning environmental areas potentially contaminated with blood-borne pathogens When cleaning a glucose meter, or any other object potentially contaminated with blood, you must use either an Environmental Protection Agency (EPA)-approved germicidal disinfectant that is labeled effective against TB or HBV, or a 1:10 bleach to water (minimal) concentration The easiest method is for facilities to have disposable wipes with bleach Manor at Blue Water Bay The Manor At Blue Water Bay Rehabilitation Center Rehab Services & Amenities Continental Breakfast Bar Individual Flat Screen TV s with DVD Player Private Phone Lines Wireless Internet Access Internet Ready Computer Café & Coffee Bar 1500 N. White Point Road, Niceville, FL

12 Manor at Blue Water Bay Changes Made to Infection Control Practices Manor at Blue Water Bay Changes made at the facility to enhance infection control program to comply with F441: 1. Implemented an Infection Preventionist - Nurse designated to serve as coordinator of the infection control program, maintain surveillance, and educate staff/families 2. Increased use of single-use medication vials and singleuse items versus multi-dose 3. Increased hand hygiene education and monitoring of nosocomial infections Changes Made to Infection Control Practices Manor at Blue Water Bay (cont.) 4. Installed gel stations in high-traffic direct-care areas 5. Started using data to detect infection trends 6. Enabled facility to change present practices as needed with increased use of relevant support data 7. Improved prevention of C. difficile spread by cleaning equipment with 1:10 dilution of bleach (sodium hypochlorite) 12

13 QIS Reporting for Infection Control..is also going to significantly change practices in LTC. CMS Releases Timeline for States Implementation of QIS (August 7, 2009) CMS announced it is pushing forward with nationwide implementation of the new Quality Indicator Survey (QIS). The QIS replaces the current survey process. To date, the QIS is in various stages of implementation. Target for all states to begin implementation is A New Survey Process Quality Indicator Survey (QIS) This is going to change things for you Demonstration project in 6 states: Connecticut, Kansas, Ohio, Florida, California, Louisiana Rolling out nationally in The goals are to: Improve consistency, accuracy of care, and QoL Perform comprehensive review of the full range of regulatory areas within current survey resource areas Enhance documentation through automation Focus survey resources on facilities with largest number of quality concerns Centers for Medicare and Medicaid Services. CMS Quality Indicator Survey Demonstration Project. Available at Accessed 5/4/10. Klusch L. Are you ready for the new survey process? The QIS is coming and now is a good time to start gearing up. a accessed 5/4/10. QIS: A Two-Stage Process Stage I Preliminary investigation of all regulated areas and determination of which areas of care will require in-depth Stage II review Stage II Determine if deficiencies are present, document, and define scope and severity Centers for Medicare and Medicaid Services. CMS Quality Indicator Survey Demonstration Project. Available at Accessed 5/4/10. 13

14 QIS vs. Traditional Survey Traditional Survey Sample roster of residents Tour includes evaluated preselected residents Residents selected based on QIs of concern Phase I and II comprehensive and focused reviews Survey completed based on samples residents Data collection on paper Interview residents, family, council QIS All residents and new admits over last 30 days Initial brief review to gain info on facility only Includes off-site, admission (30), census (40) samples Phase I preliminary investigations Phase II in-depth review of triggered areas Follow consistent protocol for conducting interview Use tablet PC to record all findings Interview residents, family council Centers for Medicare and Medicaid Services. CMS Quality Indicator Survey Demonstration Project. Available at Accessed 5/4/10. QIS Snapshot: QIS Snapshot:

15 QIS Snapshot: Practical Implications of QIS Reporting for LTCFs Infection control was very subjective in the past Surveyors did not focus heavily on infection control programs/procedures at a LTCF Now the surveyors have to inspect infection control procedures in place at a LTCF The onus is on DON to educate staff on compliance and STNA/CNA amidst increasing workload Documentation will be critical to avoid citations E.g., wound care between patients practicing HH and documenting HH paperwork Good practices will be a must CMS Guidance Mandates Homelike Environment Per CMS Guidance The LTCF must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible 15

16 CMS Recommendations for Homelike Environment Environment refers to room and common areas frequented by residents, therapy areas, outdoor areas, and activity areas CMS recommends elimination of the following: Overhead paging and piped-in music throughout the building Meal service in the dining room using trays Institutional signage labeling work rooms/closets in areas visible to residents and the public Medication carts The widespread and long-term use of audible (to the resident) chair and bed alarms Mass-purchased furniture, drapes, and bedspreads that all look alike throughout the building Large, centrally located nursing/care team stations Challenges in Balancing Infection Control With Homelike Environment It can be difficult to promote the individual resident s rights and well-being while trying to prevent and control the spread of infections and stay compliant in a homelike setting Example Problem: Potential for lapses due to discreet signage requirements Creative Signage At Manor at Blue Water Bay Patients for high fall risk identified by yellow magnets with a black star posted above patient bed Patients at risk for dehydration identified by blue tear drop magnets on patient door Reconciling CMS and CDC Guidelines The directive from CMS is that all infection prevention and control practices in LTCFs reflect current Centers for Disease Control and Prevention (CDC) guidelines However, in regard to hand hygiene and hand-washing practices, the expectation of CMS is that long-term care facilities must follow the Interpretive Guidance under F441 to comply with regulation 16

17 Reconciling CMS and CDC Guidelines in LTC DON How can we clarify variances between what the CDC and CMS expect for hand hygiene/hand washing? An action plan is needed to reconcile change. 49 The Struggle We re here to help. When you re being pulled in CMS different directions, it can CDC be difficult to stay a float. 50 Citations Alert! CMS Guidance became official in late 2009 LTCFs may have incorporated this into current practice, but they may not be up to code Citations are likely to increase in

18 The Hamburger Story Once upon a time 52 The Moral of the Story You already know that you have to wear gloves to touch a hamburger No gloves Navigating Challenging Compliance is Waters a no-no. 53 The Moral of the Story Remember to change your gloves between each resident burger preparation Bravo! 54 18

19 The Moral of the Story Don t be like Wimpy! I ll gladly wear gloves Tuesday for a hamburger today. 55 Implementing Effective Infection Control How can LTCFs quickly become aware of CMS changes and implement an effective infection program to avoid citations? Motivation: Increase staff participation in implementing changed practices to create a sense of ownership Education: Knowledge is power Increased DON involvement: Leaders lead the way. Network: Communicate with DONs at other facilities to learn from their citations and become more compliant Partnership: Accomplishing together that which cannot be done alone. Expertise Respect Knowledge 19

20 Closing Remarks: All Hands On Deck Bonnie Cruz, RN, MSN, M Ed NADONA 2010 What We Have To Do Follow guidelines in place Mandate good practices Maintain a strong track record Star system rewards successful DONs Education is critical Nursing staff Residents Families/visitors Other support staff 59 What We Should Do Think beyond guidelines and address the specific needs of each facility Education Research Testing Break the cycle Cheaper is NOT always better Influenza vaccination of all nurses saved facility $180,000/year Get creative Network Get staff involved Identify and institutionalize best practices 60 20

21 What We Should Do 61 Role of NADONA Provide tools to DONs U. S. S. Mentoring Education Information Certification programs Be a strong advocate for DONs N A D O N A Support development of articles/reports Advance clinical and scientific agendas to focus on LTC Elevate LTC s role in influencing acute care In areas of wound care, pressure sores, etc. 62 The Buck Stops Here! Taking Responsibility for Closing the Gap DON is the captain of the ship Not a SILO Be vocal, be proactive Advocate well-staffed and effective infection control programs Data is your friend use it to your advantage Know the guidelines Review infections log daily Leverage the internet Don t reinvent the wheel Use and share all available resources Learn from past mistakes Uncover precious treasure by doing the right thing! 63 21

22 Making headway: In hand hygiene vision and strategic direction Evidence-based results Planned course of action Development of competencies Questions? 65 22