By Gary Evans, Medical Writer
The Association for Professionals in Infection Control and Epidemiology (APIC) has been calling for infection preventionists (IPs) in long-term care (LTC) for years, but it took a pandemic and a catastrophic death toll among frail residents to finally spur substantive action from the government.
Since the COVID-19 pandemic began in the spring 2020 through June 26, 2022, 153,751 LTC residents and 2,433 LTC health workers have died of SARS-CoV-2 infections in the United States, according to the Centers for Medicare and Medicaid Services (CMS).1 Infections in both groups were more than 1 million. Finally, a change has come, although its ultimate effect still is a matter of discussion and concern.
In a recent memo to state surveyors, CMS requires LTC facilities “to have an IP at least part-time. Facilities are responsible for an effective Infection Prevention and Control Program (IPCP) and should ensure the role of the IP is tailored to meet the facility’s needs. With emerging infectious disease, such as COVID-19, CMS believes the role of the IP is critical in the facility’s efforts to mitigate the onset and spread of infections.”2
It sounds good, but APIC has been down this road before and ultimately has seen little meaningful change. “I think this is an important step in improving LTC resident safety, but we still have a long way to go,” says Linda Dickey, RN, MPH, CIC, president of APIC.
IP roles in LTC often have been compromised, with the job given to someone who has many other roles. Thus, the first red flag is the “at least part-time” exemption.
“‘Part-time’ has not been defined by CMS, but the interpretive guidance describes the factors that the facility must consider in determining the IP hours of work,” Dickey says. “This kind of imprecise language can easily lead to ‘diluting it down,’ because it is open to interpretation. The COVID-19 pandemic made it painfully clear that infection prevention and control is a full-time job. The IP should be not only designated but dedicated to that function.”
According to the CMS, the IP hours should be determined by a facility assessment of resources needed for its infection control program. Resources must be provided for the program in accordance with issues identified in the assessment.
“Based upon the assessment, facilities should determine if the individual functioning as the IP should be dedicated solely to the IPCP,” the CMS states in Appendix PP of the CMS State Operations Manual.3
Among factors to consider are resident characteristics; types of units, such as respiratory care, memory care, and skilled nursing; and the complexity of the healthcare services. The risk of outbreaks and seasonality of infections, such as influenza, also should be considered in the IP hours needed.
“The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees, such as [quality assurance],” the CMS states. “The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location, such as a corporate office or affiliated short-term acute care facility.”
“This is an improvement over both the original language in the 2015 proposed rule and the proposed 2019 revision,” Dickey says. There also was the so-called CMS “Mega Rule” that addressed LTC deficiencies in infection control and other areas in 2016.
“Six years and a pandemic later, we know much more about the state of patient care and staffing conditions in LTC facilities,” she said. “The Mega Rule was both not implemented and not sufficient, and we saw the result in the alarming spread of COVID-19 through LTC residents and staff during the pandemic. With the wisdom of hindsight, it is hard to be impressed with what we thought was a great step forward in 2016.”
No Comment Period
The 2022 guidance document is billed as an “advance copy” — not a draft — and it has no comment period.
“It is considered final upon release, and its effective date is Oct. 24, 2022,” Dickey says. “However, there are always ways to bring new information to the attention of CMS, legislators, state health departments, and others. APIC will continue to advocate for infection prevention in LTC.”
As outlined in the 2022 CMS operations manual, the requirements for an infection control program are fairly extensive, including training of staff, reporting and surveillance, and use of transmission-based precautions. Here are some of the areas CMS is telling its surveyors to look for, most of which would be included in employee infection control training:
- the facility’s surveillance system [is] designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;
- when and to whom possible incidents of communicable disease or infections in the facility should be reported;
- how and when to use standard precautions, including proper hand hygiene practices and environmental cleaning and disinfection practices;
- how and when to use transmission-based precautions for a resident, including, but not limited to, the type and its duration of use depending upon the infectious agent or organism involved;
- occupational health policies, including the circumstances under which the facility must enforce work restrictions and when to self-report illness or exposures to potentially infectious materials;
- proper infection prevention and control practices when performing resident care activities as it pertains to particular staff roles, responsibilities, and situations.
Moreover, the CMS stipulates if the surveyor is concerned about infection prevention and control practices or if there are healthcare associated infections in the facility, staff should be interviewed and training records reviewed. These are some questions and points for inspectors to consider:
- Did staff observations or did interviews with residents and or resident representatives indicate a training need? Did staff report not receiving training about the concern identified by the surveyor?
- What process does the facility have to encourage staff to express concerns and request training in challenging situations? Does the facility respond to staff’s concerns and requests for training?
- Has training coursework been reviewed to determine if the content meets professional standards/guidelines and covers facility policy and procedures for infection prevention and control?
- Does the facility implement the training program and ensure staff are instructed to meet the CMS requirements for infection control?
- Has the facility been verified to have a mandatory requirement that all facility staff participate in infection prevention and control training, with a process in place to track such participation?
The ultimate effectiveness of these measures will depend on how facilities implement them and how much oversight CMS, states and accreditation groups dedicate to enforcement, Dickey says.
“The CMS notes that it has also strengthened the oversight of nursing home complaints and facility-reported incidents,” she says. “But perhaps CMS should put more resources into proactive oversight, rather than waiting for complaints and incidents.”
- Centers for Medicare and Medicaid Services. COVID-19 nursing home data. Submitted data as of the week ending June 26, 2022. https://data.cms.gov/covid-19/covid-19-nursing-home-data
- Centers for Medicare and Medicaid Services. Revised long-term care surveyor guidance memorandum. Published June 29, 2022. https://www.cms.gov/files/document/qso-22-19-nh.pdf-0
- Centers for Medicare and Medicaid Services. State Operations Manual. Appendix PP - Guidance to Surveyors for Long Term Care Facilities. https://www.cms.gov/files/document/appendix-pp-guidance-surveyor-long-term-care-facilities.pdf
