By Gary Evans, Medical Writer
The Centers for Medicare and Medicaid Services (CMS) has finalized requirements in long-term care that call for at least a part-time infection preventionist (IP) and emphasizes Certification in Infection Prevention and Control (CIC) as a key credential of expertise.
IPs have been fighting for these measures for years, but it took a 100-year pandemic and the death of about 60,000 nursing home residents to finally break the inertia.
“Nursing homes were absolutely devastated by this pandemic over the past three years,” Morgan Katz, MD, MHS, of Johns Hopkins University, said recently at the IDWeek conference.
“This really did affect the majority of nursing homes across the United States,” she said. “Over 90% had more than two outbreaks up until January of 2021, and 85% of nursing homes had outbreaks lasting more than five weeks.”
Infection control in long-term care is notoriously under-resourced, so if hospitals were hard-pressed by the pandemic, it was a given nursing homes would be overrun by COVID-19. Katz consulted at nursing homes, initially shocked by the contrast with hospital IPs and epidemiologists.
“I would go to a long-term care facility and there would be maybe one half-trained IP who was dealing with a massive outbreak, and also had 100 other clinical responsibilities and no one to talk to,” she said.
Those days, hopefully, will be gone as the CMS regulations begin a sweeping culture change, but it will take time. Including the CIC credential as a mark of expertise and qualification was a big win for the Association for Professionals in Infection Control and Epidemiology (APIC). The long-standing CIC certification for IPs was created and is administered by APIC’s certification board.
“That is the only certification right now that I know of that fits the criteria of CMS,” says Linda Dickey, RN, MPH, CIC, president of APIC. “It was the only example they gave, which is great because if we can move people who are coming into long-term care toward certification, that will raise the bar on the expertise and competency in those settings.”
The CMS said in a surveyors’ guidance document that the “IP must be qualified by education, training, experience, or certification. The facility should ensure the individual selected as the IP has the background and ability to fully carry out the requirements of the IP based on the needs of the resident population, such as interpreting clinical and laboratory data. Examples of experience in infection prevention and control may include, but are not limited to, identification of infectious disease processes, surveillance and epidemiologic investigation, and preventing and controlling the transmission of infectious agents.”1
APIC wanted a requirement for a full-time IP, but long-term care is in a cost-conscious recovery mode and there also is more demand than supply of IPs for all settings. “I think that this part-time IP is a reflection of where we are right now with long-term facilities and also just the pipeline of workers,” Dickey says. “It’s a baby step, but it’s in the right direction. Just like in other healthcare professions, we are seeing people retiring in large numbers and we have lost others to burnout.”
In addition to establishing an academic track for infection prevention, APIC is trying to improve the pipeline of new IPs by getting the Department of Labor to list it as an official and specific profession.
“Right now, if you take a test to see what kind of career fits you, it doesn’t come up as an option,” Dickey says.
Risk Assessments
Again, the CMS requires the IP to be at least part-time, leaving it up to the facility and residential population to determine and define this to some degree. Part of this process must be based on a healthcare-associated infection risk assessment conducted facility-wide at least annually.
“The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPC (infection control program) 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 or 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.”
The facility must determine the risks identified and the resources needed by the IP program to prevent infections. This assessment includes the resident census, their characteristics, and the complexity of health services offered.
“Every committee I’ve been on, I think there is an agreement across the board that we need a full-time trained IPs in this setting,” Katz said. “However, we need resources to do this, and they also need to be available. A lot of the facilities I spoke with said they just can’t find one.”
Although this labor market exists, IPs can demand an appropriate salary for their training and level of experience in both acute and long-term care. “There are some people that have a heart for that [nursing home] population, but the salaries have got to be competitive,” Dickey says. “The expertise and value of the position has to be recognized.”
Getting trained IPs in nursing homes will eventually increase infection surveillance data reported to the Centers for Disease Control and Prevention (CDC). Prior to the pandemic, less than 5% of nursing homes were reporting data to the CDC’s National Healthcare Safety Network (NHSN), Katz said.
“By May 2020, all of them were required to report COVID cases, deaths, and, eventually, vaccination rates to NHSN on a weekly basis,” she said. “This is great in a lot of ways because these facilities now know how to [report to] NHSN, but they are totally overburdened. This was on top of their usual daily reporting to local and state health departments. They just cannot deal with the data requirements, and it is challenging our ability to get some of the multidrug-resistant data that we would love to have as well.”
In general, the CMS components of an infection control program in a nursing home includes a system for preventing, identifying, and controlling infections and communicable diseases that:
• covers all residents, staff, contractors, consultants, volunteers, and visitors;
• has written standards, policies, and procedures, including a system for recording identified incidents and corrective actions taken by the facility;
• has an antibiotic stewardship program (ASP). “ASP development should include leadership support and accountability via the participation of the medical director, consulting pharmacist, nursing, and administrative leadership. The IP should utilize and work collaboratively with these team members to implement the ASP,” CMS stated.
The CMS has powers to enforce these requirements, particularly its control of reimbursements for Medicare patients. The agency gave the following example of a level 4 deficiency, which is a situation that places residents’ health in immediate jeopardy.
“The facility failed to ensure the IP was qualified by education, training, experience, or certification to identify a gastrointestinal outbreak in the facility and implement appropriate control measures,” the CMS states. “Surveyors identified that the IP did not ensure that appropriate control measures (e.g., transmission-based precautions, environmental cleaning and disinfection) and reporting to public health occurred. As a result, several residents became seriously ill with diarrheal illnesses resulting in dehydration.”
The CMS also is emphasizing COVID-19 immunization of all staff, which should include documentation of vaccinations and approved exemptions. Compliance for staff immunization means having received “at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multidose COVID-19 vaccine prior to staff providing any care, treatment, or other services.” Facilities should have a process for tracking and documenting “any staff who have obtained any booster doses as recommended by the CDC.”
In stressing the importance of staff immunizations, which historically have lagged in long-term care settings, the CMS said it would give enforcement leeway to facilities that are making a good faith effort to move forward.
“CMS’s primary goal is to bring healthcare facilities into compliance,” the agency stated. “Termination [of reimbursement] would generally occur only after providing a facility with an opportunity to make corrections and come into compliance.”
“They basically said we are not trying to shut facilities down, so if you are not in compliance but on the road to getting people vaccinated [that is acceptable],” Dickey said. “But if a facility is not making a legitimate effort, they may use the stick instead of the carrot.”
Devastating Outbreaks
Nursing home COVID-19 outbreaks, particularly before the vaccines were available, ran through facilities like fire through a tinder box.
“Transmission in this setting is incredibly rapid and challenging to control, because of the nature of what you’re doing here,” Katz said. “You have a [highly] vulnerable population that requires close personal care from staff members — feeding, bathing — things that, certainly, you can’t ask a resident to wear a mask for. Sometimes staff will have to be in the room for an hour and a half at a time.”
Compliance with recommended personal protective equipment (PPE) by an immunized staff is the best way to stop a COVID-19 outbreak in long-term care, she said.
“No single intervention, particularly in this incredibly challenging setting, is going to be perfect at preventing transmission,” she said. “I can’t tell you how many conversations I had with public health officials who were saying, ‘I just went to this facility, they have amazing PPE practices, but their outbreak is still enlarging.’ If you have a facility with great PPE practices but low vaccination rates, you’re still going to have outbreaks and problems. If you have a facility with great vaccination rates but they have terrible staff sick leave — staff feel like they have to come in when they’re sick to make a living wage — you’re still going to have outbreaks.”
Other contributing factors to outbreaks include that nursing homes traditionally have not had respiratory protection programs and many older facilities have inadequate ventilation. The Occupational Safety and Health Administration (OSHA) included requirements in these areas for nursing homes in its temporary standard for COVID-19, which is being finalized.2,3 (See Hospital Infection Control & Prevention, June 2022). Setting up a respiratory protection program is no small task, and nursing homes should begin laying the groundwork for this, Katz said.
“You need an administrator to lead the program and a physician to perform all your medical assessments,” she said. “You have to perform yearly fit testing of the staff, and then regular training on respiratory use, sometimes in facilities that have 100% staff turnover rates. It’s a huge endeavor for these facilities to get in place.”
Ultimately, infection control in long-term care should adopt strategic monitoring and feedback on practices and compliance, Katz said.
“In acute care, it took about 10 to 15 years to really embed this in our infection prevention programs, and I think that this is the direction we’re going in long-term care,” she said. “And we all know that even excellent policies don’t automatically translate into excellent practices. The way most nursing homes work is that someone in leadership will come through and do an occasional audit, and then penalize whoever is not following the practices. That, unfortunately, does not really lead to sustainable change.”
Routine, systematic observation and feedback on, for example, hand hygiene compliance and use of PPE can begin to set expectations in long-term care. Katz stressed the “importance of really taking back these data to front-line staff and using positive reinforcement to start to change the culture in these facilities.”
Long-term care staff will respond favorably if the message is that infection control protects the residents, she said.
“They really are there because they care about the residents,” she said. “Housekeeping staff light up when you explain to them how the work that they do prevents infections in the residents. It’s often not framed that way to them.”
Similarly, nursing home staff need to be recognized for what they do and be paid more to do it. Certified nursing assistants, who provide 80% to 90% of direct care needs to nursing home residents, make an average of $12.89 per hour and have minimal benefits, Katz said.
“We really need to elevate the position and reimburse them for the work that they do,” she said. “I will tell you, direct care staff in nursing homes — those who are still there after this pandemic — are there because they care about the residents.”
In particular, facilities need to target the high turnover rates that make it difficult to instill infection prevention education and basic practices.
“I cannot tell you what these facilities have been through the past three years,” Katz said. “This is the moment we need to learn from what happened and prevent this, not just for the next pandemic but for multidrug-resistant organisms and other emerging threats in this setting.”
REFERENCES
- Centers for Medicare and Medicaid Services. State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities. Revised Oct. 21, 2022. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf
- Occupational Safety and Health Administration. Occupational exposure to COVID-19 in healthcare settings. Published March 23, 2022. https://www.osha.gov/laws-regs/federalregister/2022-03-23-0
- Occupational Safety and Health Administration. Subpart U — COVID-19 emergency temporary standard. https://www.osha.gov/sites/default/files/covid-19-healthcare-ets-reg-text.pdf
The Centers for Medicare and Medicaid Services has finalized requirements in long-term care that call for at least a part-time infection preventionist and emphasizes Certification in Infection Prevention and Control as a key credential of expertise.
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