LAFAYETTE PARISH SHERIFF S OFFICE CORRECTIONS DIVISION Section/Policy: T-1600 POLICY AND PROCEDURES Subject: Number of Pages: 9 7 ACADIANA RECOVERY CENTER INFECTION CONTROL PROGRAM References: ACA: 4-ALDF-4C-14 CARF: 1.H.9; 1.H.11; 1.H.3 NCCHC: J-B-01 (Essential); LAC: 51 (Public Health Sanitary Code), Part II, Chapter 1, 101 (formerly 2:001); 51 (Public Health Sanitary Code), Part II, Chapter 1, 105(A.1.a) (formerly 2:003); OSHA: 29 CFR1910.1030(b) Corrections Division Policy and Procedure: A-5400; D-1200; H-2600; H-2800; T- 1700; T-1300 Approved by: Treatment Programs Manager: Health Care Authority: Director of Corrections: Revision/Review dates: Originated: 10/24/14; Revised: 11/13/15 T-1600 POLICY: To minimize the risk of harm to participants and staff, the Acadiana Recovery Center shall create and implement an Infection Control Program that addresses infection education, the prevention of infection, infection control, and the Standard (Universal) Precautions for infection transmission. (1.H; 1.H.11; J-B-01; 4-ALDF-4C-14) T-1601 DISCUSSION: The function of the Infection Control Program is to monitor, prevent, and control infections and infectious diseases among all patients and staff. It is further the purpose of the Infection Control Program to provide a forum of Page 1 of 7 Policy T-1600
education to patients and staff regarding the nature of infections and infectious diseases, and the prevention of such. T-1602 DEFINITIONS: A. Communicable Disease: An illness due to a specific infectious agent or its toxic products which arises through transmission of that agent or its products from a reservoir to susceptible host, either directly as from an infected person or animals, or indirectly through the agency of an intermediate plant or animal host, a vector or the inanimate environment. (H-2600) B. Reportable Disease: Any disease or condition for which an official report is required by the State Health Officer. (LAC: 51 (Public Health Sanitary Code), Part II, Chapter 1, 101 (formerly 2:001); H-2600) C. Health Care Authority: An individual licensed to practice medicine in the state of Louisiana that is contracted through the Lafayette Parish Sheriff s Office to serve as the final responsibility for decisions related to health care judgments for participants under treatment at the Acadiana Recovery Center. (T-1700) D. Performance Improvement Committee: A group of staff and professionals that meet at least quarterly to ensure that behavioral health services at Acadiana Recovery Center are provided in an environment that adheres to and documents established standards of accountability for administrative, business, clinical, and financial management. (4-ALDF-4C-14) E. Standard (Universal) Precautions: Requires that a person assume that blood and body fluids, non-intact skin and moist mucus membranes from all persons are potentially infectious. The employee anticipates the interaction and selects physical barriers (gloves, gown and facial protection) necessary to minimize the risk of a bloodborne exposure. Exposure controls have been established for employees who encounter blood and body fluid in their daily practice, but judgment is also necessary. Each individual must establish their own standards for consistent use of barriers. (H-2800) F. Participant: Page 2 of 7 Policy T-1600
T-1603 RULES: Any individual who is provided services and/or training through a Corrections Division program. A. The Health Care Authority shall have the authority to institute any surveillance, prevention, and control measures or studies deemed appropriate when there is a reason to believe that any patient or staff member may be in danger of infection. B. The Treatment Programs Manager shall authorize the development and implementation of the Infection Control Program to encompass all areas of patient care. C. The Infection Control Program shall function as an aspect of the Performance Improvement Committee. D. The Registered Nurse (RN) shall report infectious and communicable diseases to the participants, staff, physicians, and to the Louisiana Department of Health and Human Services, Division of Public Health as soon as possible, but no later than 24 hours from recognition, that an outbreak is known. (LAC: 51 (Public Health Sanitary Code), Part II, Chapter 1, 105(A.1.a) (formerly 2:003)) E. When safety concerns are identified for participants, information and training relative to that risk shall be offered as a means to reduce risk and promote safety. (1.H.3) F. Acadiana Recovery Center shall not accept participants with an active, infectious, or communicable disease. (T-1300) G. The Registered Nurse (RN) shall oversee all pertinent activities of the Infection Control Program. H. All infectious or communicable conditions shall be documented in the participant s record by the Health Care Authority or the nurse and followed accordingly to resolution. I. The Health Care Authority or the nurse shall document referrals to medical consultants. J. A report shall be made regarding any staff member(s) with infections; these reports shall be kept in the employee s file. K. Staff who may have been exposed to a communicable disease shall take reasonable measures to identify the source and shall report the exposure to Page 3 of 7 Policy T-1600
their immediate supervisor. (1.H.11; A-5400) L. Staff shall apply Standard (Universal) Precautions when coming in contact with the participant and the participant s environment regardless of the participant s diagnosis or presumed infection status and shall be practiced in any situation involving blood or other potentially infectious materials (OPIM) and all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood, non-contact skin or mucous membranes. (1.H.11; OSHA: 29 CFR 1910.1030(b)) M. Standard (Universal) Precautions supplies shall be maintained at all times. T-1604 PROCEDURES: A. To ensure that the Infection Control Program is properly implemented, the Registered Nurse (RN) shall, at a minimum: 1. Conduct all monitoring of rated nosocomial (facility-acquired) infections; 2. Develop systems used to collect and analyze data; 3. Prepare corrective action plans and assign responsibility to health care staff; 4. Conduct activities to prevent and control infections and communicable diseases; 5. Report infection control data of all monitored areas to the Performance Improvement Committee. a. Data collection for the Infection Control Program monitoring and evaluation may include, but is not limited to: (1) Monthly facility inspection for cleanliness of all living areas, availability and completeness of universal precautions supplies, availability of cleanliness supplies, etc.; (2) Monthly kitchen inspection for cleanliness of all areas, proper refrigerator temperatures, proper food storage, availability of cleaning supplies and proper storage of poisonous, toxic and flammable materials; Page 4 of 7 Policy T-1600
(3) Number and types of patient infections. B. The following infection control information shall be addressed at the Performance Improvement Committee quarterly meetings: (4-ALDF-4C- 14) 1. Findings shall be discussed and reported to the Treatment Programs Manager; 2. Trends shall be noted; 3. Corrective actions shall be recommended; 4. Needs of further staff education regarding infectious or communicable diseases shall be identified. C. Before acceptance for treatment and residency at the Acadiana Recovery Center, the Registered Nurse (RN) shall perform an assessment of each potential participant to identify possible infectious or communicable diseases. 1. The Registered Nurse (RN) shall review the potential participant s past medical record and ascertain that the state requirements concerning infectious or communicable diseases are met. The results shall be placed in the participant s record. a. If the potential participant has had recent care for chemical dependency in a primary residential treatment facility, the history and physical shall be requested from that facility in accordance with confidentiality guidelines; b. If the potential participant has not had recent care for chemical dependency in a primary residential treatment facility, or if the potential participant s history and physical are not available, the Registered Nurse (RN) or Licensed Practical Nurse (LPN) shall collect the potential participant s history and physical data from the potential participant prior to acceptance to the Acadiana Recovery Center. c. If it is determined that the potential participant currently has certain medical conditions (e.g., diabetes, open wounds, uncontrolled hypertension, any medications that require lab monitoring, etc.), the potential participant shall not be accepted and shall be given an explanation for the decision Page 5 of 7 Policy T-1600
and provided with an appropriate referral to another treatment provider. D. If at any time, health care staff suspect an outbreak related disease: 1. The health care staff shall notify the Registered Nurse of possible infection. 2. The Registered Nurse shall: a. Notify the Health Care Authority of a referral of possible infection; b. Notify the Louisiana Department of Health and Human Services, Division of Public Health by telephone or by completing and submitting the appropriate report forms via computer to the Louisiana Department of Health and Human Services, Division of Public Health. c. Inform all facility staff, physicians, and others that may potentially come in contact with the infected participant. d. Document in the participant s record any referral to the Health Care Authority of possible infection. e. All infectious or communicable conditions shall be documented in the participant s record by the Health Care Authority or nurse and followed accordingly to resolution. The Health Care Authority or nurse shall document referrals to medical consultants. E. Infection Control Training: : 1. All staff of the Acadiana Recovery Center shall receive in-service instruction by a member of the LPSO nursing staff in matters relevant to the Infection Control Program, including Standard (Universal) Precautions. Documentation of the in-service education shall be placed in the staff s personnel folder to be considered in annual evaluations. (1.H.11; D-1200) 2. New staff shall receive similar education in conjunction with orientation to their duties. Documentation of such education shall be placed in the staff s personnel folder. (D-1200) 3. All participants shall receive education in Infection Prevention procedures, including Standard (Universal) Precautions, during their orientation to the facility. (1.H.11; D-1200) Page 6 of 7 Policy T-1600
F. Procedures for staff who may have been exposed to a communicable disease: (A-5400) 1. Staff who may have been exposed to a communicable disease shall take reasonable measures to identify the source and report the exposure to their immediate supervisor. 2. When an exposure occurs, wash the exposed area immediately with soap and water. Report to the Health Care Section when eyes are exposed. 3. The employee shall complete an On-Job Injury Report, the appropriate Incident Report, and notify their immediate supervisor. When completing such reports, staff shall be as specific as possible when describing the incident and shall include: a. Body fluid involved (i.e., blood); b. Exposure site (i.e., cut on right hand); c. Means of exposure (i.e., blood into open cut); d. List PPE items worn at the time of exposure. If items(s) were not worn, specify why the equipment was not, or could not, be utilized. 4. After notifying an immediate supervisor, the employee shall report to their preferred hospital for necessary treatment. 5. The staff member shall be evaluated by a physician, who shall perform the appropriate blood tests (with the employee s authorization), answer all questions, and instruct the employee on any additional follow-up that may be necessary. 6. The employee s health care provider shall provide all follow-up care. Page 7 of 7 Policy T-1600