model z } ] v p w l p ( } > ong term care & ] o ] ] } } ] … reporting...3. submit a c } u o...

Model Reporting Package for Long Term Care Facilities

This packet has been developed to simplify and combine all information required to be provided to OSDH to meet the requirements specified in Oklahoma's Phased Reopening in Long-Term Care Facilities under Infection Preventionist.

Submittal of this material is not required prior to facilities implementing their reopening plans.You will receive an email approving your infection preventionist, the risk assessment and monitoring plan. This approval is required for any Oklahoma LTC CARES Grant award.

If you have already submitted portions of this material please send any remaining required documents.

1. Complete the form or submit other equivalent materials to identify your InfectionPreventionist, with the required information.

2. Provide evidence of the Infection Preventionist's training.

3. Submit a completed Infection Prevention & Control Risk Assessment using the CDC orequivalent template included in the packet.

4. Create and submit a Monitoring Plan based on the CDC's Infection Prevention and Controlor equivalent training addressing:

Infection surveillance Competency-based training of Health Care Personnel (HCP) Adherence to recommended Infection Prevention and Control (IPC) practices, and Adherence to recommended personal protective equipment (PPE) practices.

5. Your monitoring plan will incorporate an IPC Monitoring Tool. You may use the formprovided by the Department in this packet or provide one for the Department's review andapproval. Performance monitoring by the IP of the facility's IPC should reflect all shifts andbe done not less than every two weeks. OSDH may request monitoring documentation inorder to meet sampling requirements.

6. The facility shall report their Initial Phase Reopening Status and any changes to the LongTerm Care Service of the OSDH on the form provided.

All submissions should be directed to:

Long Term Care Services [email protected]

or mail to:

Long Term Care Services Oklahoma State Department of Health 1000

NE 10th StreetOklahoma City, OK 73117 405.271.6868

https://coronavirus.health.ok.gov/sites/g/files/gmc786/f/oklahoma_reopening_in_long_term_care_facilities_final_20200610.pdf

Infection Preventionist (IP) Information

Facility Name Facility ID IP Name IP Address IP eMail IP Phone IP Licensed Credentials

Please include evidence of the infection preventionist training. Provide the Department evidence the IP completed the CDC's Nursing Home Infection Preventionist Training Course or the American Health Care Association's Infection Control Specialist Certification, submit to:


or mail to:

Long Term Care Services Oklahoma State Department of Health 1000 NE 10th Street Oklahoma City, OK 73117 405.271.6868

mailto:[email protected]

https://www.train.org/cdctrain/training_plan/3814

Facility Monitoring Plan

Facility Name Facility ID Facility Address Facility eMail Facility Phone Facility Contact

Provide a monitoring plan for the facility that includes:

• Infection surveillance,• Competency-based training of Health Care Personnel (HCP)2,• Adherence to recommended Infection Prevention and Control (IPC) practices, and• Adherence to recommended personal protective equipment (PPE) practices;• This assessment is not the CDC's Infection Prevention and Control Assessment Tool for

Nursing Homes Preparing for COVID-19 but is a comprehensive infection controlassessment that will be expanded for COVID-19 and adapted to the facility type. Theassessment will have been performed or updated on or after the issuance of this plan,to account for the guidance and requirements in this plan, including the facility'svisitation and outings policies.

Please include a plan and submit to:


or mail to:



VERSION 1.3.1 SEPTEMBER 2016 3

Section 2: Infection Control Program and Infrastructure

I. Infection Control Program and Infrastructure

Elements to be assessed Assessment Notes/Areas for Improvement

A. The facility has specified a person (e.g., staff, consultant) who isresponsible for coordinating the IC program. Yes No

Click here to enter text.

B. The person responsible for coordinating the infectionprevention program has received training in IC

Examples of training may include: Successful completion of initial and/or recertification exams developed by the Certification Board for Infection Control & Epidemiology; Participation in infection control courses organized by the state or recognized professional societies (e.g., APIC, SHEA).

Yes No


C. The facility has a process for reviewing infection surveillancedata and infection prevention activities (e.g., presentation at QAcommittee).

Yes NoClick here to enter text.

D. Written infection control policies and procedures are availableand based on evidence-based guidelines (e.g., CDC/HICPAC),regulations (F-441), or standards.

Note: Policies and procedures should be tailored to the facility and extend beyond OSHA bloodborne pathogen training or the CMS State Operations Manual

Yes No


E. Written infection control policies and procedures are reviewedat least annually or according to state or federal requirements,and updated if appropriate.


F. The facility has a written plan for emergency preparedness (e.g.,pandemic influenza or natural disaster). Yes No Click here to enter text.

II. Healthcare Personnel and Resident Safety


Healthcare Personnel

A. The facility has work-exclusion policies concerning avoidingcontact with residents when personnel have potentiallytransmissible conditions which do not penalize with loss ofwages, benefits, or job status.


B. The facility educates personnel on prompt reporting ofsigns/symptoms of a potentially transmissible illness to asupervisor


C. The facility conducts baseline Tuberculosis (TB) screening for allnew personnel Yes No Click here to enter text.

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention


II. Healthcare Personnel and Resident Safety, continued

Elements to be assessed Assessment Notes/Areas for Improvement D. The facility has a policy to assess healthcare personnel risk for

TB (based on regional, community data) and requires periodic(at least annual) TB screening if indicated.


E. The facility offers Hepatitis B vaccination to all personnel whomay be exposed to blood or body fluids as part of their jobduties


F. The facility offers all personnel influenza vaccination annually. Yes No Click here to enter text.

G. The facility maintains written records of personnel influenzavaccination from the most recent influenza season. Yes No


H. The facility has an exposure control plan which addressespotential hazards posed by specific services provided by thefacility (e.g., blood-borne pathogens).

Note: A model template, which includes a guide for creating an exposure control plan that meets the requirements of the OSHA Bloodborne Pathogens Standard is available at: https://www.osha.gov/Publications/osha3186.pdf

Yes No


I. All personnel receive training and competency validation onmanaging a blood-borne pathogen exposure at the time ofemployment.

Note: An exposure incident refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the

Yes No


J. All personnel received training and competency validation onmanaging a potential blood-borne pathogen exposure withinthe past 12 months.


Resident Safety

A. The facility currently has a written policy for to assess risk for TB(based on regional, community data) and provide screening toresidents on admission.


B. The facility documents resident immunization status forpneumococcal vaccination at time of admission.

Yes No Click here to enter text.

C. The facility offers annual influenza vaccination to residents. Yes No Click here to enter text.



III. Surveillance and Disease Reporting


Surveillance

A. The facility has written intake procedures to identify potentiallyinfectious persons at the time of admission.

Examples: Documenting recent antibiotic use, and history of infections or colonization with C. difficile or antibiotic-resistant organisms

Yes No


B. The facility has system for notification of infection preventioncoordinator when antibiotic-resistant organisms or C. difficileare reported by clinical laboratory.


C. The facility has a written surveillance plan outlining the activitiesfor monitoring/tracking infections occurring in residents of thefacility.


D. The facility has system to follow-up on clinical information, (e.g.,laboratory, procedure results and diagnoses), when residentsare transferred to acute care hospitals for management ofsuspected infections, including sepsis.

Note: Receiving discharge records at the time of re-admission is not sufficient

Yes No


Disease Reporting

A. The facility has a written plan for outbreak response whichincludes a definition, procedures for surveillance andcontainment, and a list of syndromes or pathogens for whichmonitoring is performed.


B. The facility has a current list of diseases reportable to publichealth authorities.


C. The facility can provide point(s) of contact at the local or statehealth department for assistance with outbreak response.


IV. Hand Hygiene

Elements to be assessed Assessment Notes/Areas for Improvement A. Hand hygiene policies promote preferential use of alcohol-

based hand rub (ABHR) over soap and water in most clinicalsituations.

Note: Soap and water should be used when hands are visibly soiled (e.g., blood, body fluids) and is also preferred after caring for a patient with known or suspected C. difficile or norovirus during an outbreak or if rates of C. difficile infection in the facility are persistently high.

Yes No




IV. Hand Hygiene, continued

Elements to be assessed Assessment Notes/Areas for Improvement B. All personnel receive training and competency validation on HH

at the time of employment. Yes No Click here to enter text.

C. All personnel received training and competency validation onHH within the past 12 months.


D. The facility routinely audits (monitors and documents)adherence to HH

Note: If yes, facility should describe auditing process and provide documentation of audits


E. The facility provides feedback to personnel regarding their HHperformance.

Note: If yes, facility should describe feedback process and provide documentation of feedback reports


F. Supplies necessary for adherence to HH (e.g., soap, water, papertowels, alcohol-based hand rub) are readily accessible inresident care areas (i.e., nursing units, resident rooms, therapyrooms).


V. Personal Protective Equipment (PPE)

Elements to be assessed Assessment Notes/Areas for Improvement A. The facility has a policy on Standard Precautions which includes

selection and use of PPE (e.g., indications, donning/doffingprocedures).


B. The facility has a policy on Transmission-based Precautions thatincludes the clinical conditions for which specific PPE should beused (e.g., C. difficile, Influenza).


C. Appropriate personnel receive job-specific training andcompetency validation on proper use of PPE at the time ofemployment.


D. Appropriate personnel received job-specific training andcompetency validation on proper use of PPE within the past 12months.


E. The facility routinely audits (monitors and documents)adherence to PPE use (e.g., adherence when indicated,donning/doffing).


Yes No


F. The facility provides feedback to personnel regarding their PPEuse.



G. Supplies necessary for adherence to proper PPE use (e.g.,gloves, gowns, masks) are readily accessible in resident careareas (i.e., nursing units, therapy rooms).




VI. Respiratory Hygiene/Cough Etiquette

Elements to be assessed Assessment Notes/Areas for Improvement A. The facility has signs posted at entrances with instructions to

individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?

Yes No


B. The facility provides resources for performing hand hygiene near the entrance and in common areas. Yes No Click here to enter text.

C. The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility. Yes No Click here to enter text.

D. The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?


E. All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens




IX. Environmental Cleaning

Elements to be assessed Assessment Notes/Areas for Improvement A. The facility has written cleaning/disinfection policies which

include routine and terminal cleaning and disinfection of resident rooms.


B. The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. difficile).


C. The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas.


D. The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.).


E. Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, and dental equipment) are cleaned and reprocessed appropriately prior to use on another patient.

Note: If external consultants (e.g., wound care nurses, dentists or podiatrists) provide services in the facility, the facility must verify these providers have adequate supplies and space to follow appropriate cleaning/disinfection (reprocessing) procedures to prevent transmission of infectious agents

Note: Select not applicable for the following: 1. All medical devices are single use only or dedicated to

individual residents 2. No procedures involving medical devices are performed in

the facility by staff or external consultants 3. External consultants providing services which involve

medical devices have adequate supplies that no devices are shared on-site and all reprocessing is performed off-site

Yes No Not Applicable


F. Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment.

Note: If environmental services are performed by contract personnel, facility should verify that training is provided by contracting company

Yes No




IX. Environmental Cleaning, continued


G. Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months.

Note: If environmental services are performed by contract personnel, facility should verify that training is provided by contracting company

Yes No


H. The facility routinely audits (monitors and documents) quality of cleaning and disinfection procedures.


Yes No


I. The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures.


Yes No


J. Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered, including products labeled as effective against C. difficile and Norovirus) are available.

Note: If environmental services are performed by contract personnel, facility should verify that appropriate EPA-registered products are provided by contracting company

Yes No


Section 3: Direct Observation of Facility Practices (optional)

Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container that is used for subsequent patients; reuse of lancets) can result in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected patients.



Hand Hygiene and Contact Precautions Observations

Staff type* Type of opportunity HH performed? Gown or glove indicated? Gown/glove used? Click here to enter text.

Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.

Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither



Alcohol-rub

Hand Wash

No HH done

Gown only

Glove only

Both

No

Gown used

Glove used

Both

Neither *Staff key: MD= Physician, PA= Physician assist., NP= Advanced practice nurse, RN=Registered nurse, LPN=Licensed practice nurse, CNA=Certified nurse aide or assist., REHAB= Rehabilitation staff (e.g. physical, occupational, speech), DIET=Dietary staff, EVS=Environmental services or housekeeping staff, SW = Social worker, UNK = Unknown/unable to determine


VERSION 1.3.1 SEPTEMBER 2016

Assessment Summary

Click to update summary tables

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I. Infection Control Program and Infrastructure

Notes/Recommendations: Click here to enter text.

II. Healthcare Personnel and Resident Safety


III. Surveillance and Disease Reporting


IV. Hand Hygiene


V. Personal Protective Equipment (PPE)


VI. Respiratory/ Cough Etiquette


VII. Antibiotic Stewardship


VIII. Injection safety and Point of Care Testing



VERSION 1.3.1 SEPTEMBER 2016

IX. Environmental Cleaning


Follow Up Activities:

Repeat on-site assessment planned (date: Click here to enter a date.)

Repeat remote (phone/email) assessment planned (date: Click here to enter a date.)

Other (specify): Click here to enter text.

Other Comments:


Click to hide/collapse summary tables that are unchecked below

(Please allow one minute to complete)

IC Program and Infrastructure HCP Safety Surveillance/Reporting Hand Hygiene PPE

Respiratory Etiquette Antibiotic Stewardship Injection Safety/POC Testing Environmental Cleaning


Staff PPE Usage Grid for Resident Interactions

Surg

ical

Mas

k

N95

Mas

k

Glo

ves

Eye

Prot

ectio

n

Gow

ns

Negative and General Facility XNo Direct Care or Contact with Unknown or Quarantined) X XUnknown X X X XQuarantine X X X XSuspected X X X XPerson Under Invesigation X X X XCOVID Positive X X X X

Resident Status

Facility Phase Notification

Facility Name Facility ID Facility Address Facility eMail Facility Phone Facility Contact

Provide phase status for the facility:

Phase 1 – Date Entered:_______________ Date Exited:_______________ # of Days:_____

Phase 2 – Date Entered:_______________ Date Exited:_______________ # of Days:_____

Phase 3 – Date Entered:_______________

Please submit to:


or mail to:



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