infection control & prevention (ic) table of contents · policy: the primary purpose of the...

POLICIES AND PROCEDURES

Infection Control & Prevention (IC)

Table of Contents

IC-01 Infection Control & Prevention Program IC-02 HBV/HIV IC-03F Reportable Diseases Florida IC-03T Reportable Diseases Tennessee IC-04 Needle Sticks and Cuts IC-05 Universal Precautions Category I and II Tasks IC-06 Infection Control Reporting IC-07 Resident and Staff T. B. Testing IC-08T Resident and Staff Tetanus Vaccine IC-09 Resident and Staff Influenza Prevention IC-10 Hand Hygiene and Respiratory Etiquette

POLICIES AND PROCEDURES SUBJECT: INFECTION CONTROL & PREVENTION PROGRAM Page 1 of 2 ISSUE DATE: June 30, 2002 Policy No. IC-01 REVISION DATE: March 31, 2014 PROGRAM: All Programs

POLICY: The primary purpose of the infection control and prevention program is to establish guidelines to follow in preventing, controlling, and eliminating the spread of contagious, infectious, and/or communicable disease. These policies and procedures apply equally to all personnel, residents, visitors and the general public, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status. The objectives of our infection control program are to: 1. Surveillance, prevention and control the spread of communicable/contagious disease. 2. Maintain a sanitary environment for our personnel, residents, visitors and the general public. 3. Develop alternative techniques to address the real and potential exposures. 4. Select and implement the best techniques to minimize adverse outcomes. 5. Evaluate and monitor the results and revise techniques as needed. 6. Ensure that OSHA regulations and pertinent federal, state and local regulations to infection control are

followed. PROCEDURES: 1. It shall be the responsibility of the Nurse Manager to ensure that all infection control policies and

procedures are implemented and followed. 2. The Nurse Manager shall be responsible for making periodic report to the Safety

Committee/Management Team concerning changes in our established infection control practices and to facilitate a multidisciplinary approach to the prevention and control of infections.

3. All personnel shall be informed of our infection control policies and procedures through our

orientation program and regularly scheduled in-service training classes. 4. Prevention of Infectious Diseases:

A. Infection disease prevention measures include both mandatory and voluntary testing and immunization for employees.

B. A physician's permit to return to work is required following any suspicion of an infectious

disease. C. Resident TB testing completed at admission and annually. Staff TB testing is done upon hire

and annually.

D. In-services of proactive prevention and education of infection to reduce and control the spread of infection is conducted both with residents and all staff by Nurse Manager or designee.


E. Availability of personal protective equipment (PPE) for personnel at risk of accidental

exposure to blood and/or body fluids. Wiping down of common areas with antiseptic wipes daily. Use of PPE or antiseptic wipes may increase if infectious rates increase.

F. Surveillance of the environment will include the Nurse Manager participating in

environmental rounds at least monthly to monitor potential infection control issues in the environment. Surveillance may be increased if infectious rates increase.

G. The Nurse Manager is responsible for monitoring of infectious rates monthly/annually and

tracking performance measures to identify trends and adjust education, policies and procedures as needed.

H. Staff and Resident who frequent animal care facilities will be offered a tetanus vaccine.

6. Our infection control and prevention policies and procedures will be reviewed for revision and

updating as necessary, but at least annually. 7. Such policies and procedures will be reviewed by the Nurse Manager, Compliance Manager, Safety

Committee, as well as other committees annually, for their content and effectiveness. 8. ALL staff are responsible for reporting suspected infections and infection control issues to the Nurse

Manager. 9. Any suspected increase or outbreak of infectious illness among staff and residents will be reported to

the local Department of Health by the Nurse Manager. Additional measure will include; a. Notification of the outbreak to the Risk Manager and Management team members. b. Increase staff and resident education about hand hygiene and respiratory etiquette.

c. Staff and residents will be offered ear loop masks to prevent the continued spread of airborne illness.

d. Common areas may be wiped down with antiseptic wipes on each shift. e. The Risk Manager may suspend new Admissions to the affected program. f. Internal resources or external vendors may be used to disinfect the facility.

2014 Infection Control Plan

GOAL: For 2014, the Nurse Manager will assess the most common infections in the environment and collect data to set performance measures for the following year. MEASURE: The Nurse Manager will track infection types and rates on the Infection Control tally monthly to be analyzed at the end of the year.

POLICIES AND PROCEDURES SUBJECT: HBV/HIV Page 1 of 2 ISSUE DATE: June 30, 2002 Policy No. IC-02 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: All Programs POLICY: It is the policy of RHG to follow Center for Disease Control Guidelines and to maintain confidentiality of all employees relative to HBV/HIV status. PROCEDURE: 1. HBV/HIV positive employees need not be restricted from work, but infected employees should be

evaluated on an individual basis. Our facility will not discriminate against an HBV/HIV-positive employee. The employee would be expected to alert the facility that he/she is HBV/HIV -positive. As with any other employee, he or she would have to demonstrate their physical and mental well-being to handle the specific job responsibilities. The infected employee is expected to observe and follow basic infection control procedures and be diligent in following CDC’s Universal Precautions.

2. Routine screening of employees for the HBV/HIV will not be done. 3. Confidentiality will be maintained at all times to insure the privacy of the employee, unless the

employee gives permission to share the information. Anyone, however, who has a business related reason to know about an employee with HBV/HIV, will be informed.

4. All employees are expected to work with any residents (including HBV/HIV-positive residents or

infected co-workers) unless the employee has written medical certification from a physician regimenting that an individual not be exposed to residents or staff who are HBV/HIV-positive.

5. All attempts will be made to dispel myths about transmission of HBV/HIV. 6. Those employees who are HBV-positive or seroconvert during the course of employment must present

a medical certificate affirming that he/she is antibody positive for HBV. 7. Follow-up Procedures After Possible Exposure to HIV/HBV:

(a) If an employee has a percutaneous (needle stick or cut) or mucous membrane (splash to eye, nasal mucosa or mouth) exposure to body fluids or has a cutaneous exposure to blood when the employee's skin is chapped, abraded or otherwise non-intact, the source resident shall be informed of the incident and tested for HIV and HBV infections, after consent is obtained.

(b) If resident consent is refused or if the source resident tests positive, the employee shall be

evaluated clinically and by HIV antibody testing as soon as possible and advised to report and seek medical evaluation of any acute febrile illness that occurs within 12 weeks after


exposure. HIV seronegative employees shall be retested 6 weeks post-exposure and on a periodic basis thereafter (12 weeks, 6 months and 12 months after exposure.)

(c) Follow up procedures shall be taken for employees exposed or potentially exposed to HBV.

The types of procedures depends on the immunization status of the employee (i.e., whether HBV vaccination has been received and antibody response is adequate) and the HBV serologic status of the source resident. The CDC Immunization Practices Advisory Committee has published its recommendations regarding HBV post-exposure prophylaxis in table format in the June 7, 1985, Morbidity and Mortality Weekly Report.

(d) If an employee refuses to submit to the procedures in (b) or (c) above when such procedures

are medically indicated, no adverse action can be taken on that ground alone, since the procedures are designed for the benefit of the exposed employee.

8. New employees will be advised that HBV/HIV residents may be admitted and that HBV/HIV positive

employees will not be discriminated against or terminated because of that condition unless the employee is not capable to do required job tasks.

9. HBV vaccine will be offered to new employees with Category I exposure within 10 days of initial employment (or at a later date per their request), free of charge to the employee. Employees may produce previous vaccination records or sign a declination that will be kept in the Human Resource file.

10. Employees with Category I exposure who choose to decline HBV vaccine must sign the HBV declination form.


SUBJECT: REPORTABLE DISEASES FLORIDA Page 1 of 3 ISSUE DATE: June 30, 2002 Policy No. IC-03F REVIEW/REVISION DATE: March 31, 2014 PROGRAM: All Programs POLICY: It is the policy of RHG to report all infections, and contagious or communicable diseases to appropriate county and/or state health department officials. PROCEDURES: Should a resident or employee be suspected of or diagnosed as having any of the following diseases, it shall be promptly reported to the Nurse Manager, who will then notify appropriate county and/or State of Florida Health Department officials. Diseases or conditions listed in subsection below are of public health significance identified by the Department as of the date of these rules which must be reported by the practitioner, hospital, laboratory, or other individuals via telephone (with subsequent written report within 72 hours, see Rule 64D-3.030 – 3.033, F.A.C.), facsimile, electronic data transfer, or other confidential means of communication to the County Health Department having jurisdiction for the area in which the office of the reporting practitioner, hospital, laboratory or patient’s residence is located consistent with the specific section and time frames in subsection below relevant to the practitioners, hospitals and laboratories, respectively. Reporters are not prohibited from reporting diseases or conditions not listed by rule. The potential or suspect cases of disease might be based on a positive laboratory test, clinical symptoms, or epidemiologic criteria. Public health investigations are usually conducted to determine and implement appropriate public health interventions. “Suspect Immediately” or “Immediately”-- Reports that cannot timely be made during the County Health Department business day shall be made to the County Health Department after-hours duty official. If unable to do so, the reporter shall contact the Florida Department of Health after hours duty official at (850) 245-4401. “Next Business Day” – Report before the closure of the County Health Department’s next business day following suspicion or diagnosis.


Practitioner Reporting

Notifiable Diseases or Conditions

Suspect Imm

ediately

Imm

ediately

Next Business Day

Other

Notifiable Diseases or Conditions

Suspect Imm

ediately

Imm

ediately

Next Business Day

Other

Any case, cluster of cases, or outbreak of a disease or condition found in the general community or any defined setting such as a hospital, school or other institution, not listed in this Rule that is of urgent public health significance. This includes those indicative of person to person spread, zoonotic spread, the presence of an environmental, food or waterborne source of exposure and those that result from a deliberate act of terrorism.

X X

Listeriosis

Acquired Immune Dificiency Syndrome (AIDS)

2 weeks Lyme disease

X

Amebic Encephalitis

X

Lymphogranuloma Venereum (LGV) X

Anthrax X X

Malaria X Arsenic *2

X Measles (Rubeola) X X

Botulism, Foodbourne X X

Melioidosis X X


Botulism, Infant

X

Meningitis, bacterial, cryptococcal and mycotic (other than meningococcal or H. influenzae or pneumococcal)

X

Brucellosis

X X

Meningococcal Disease, includes meningitis and meningococcemia

X X

California Serogroup virus neuroinvasive and non-neuroinvasive disease

X

Mercury poisoning

X

Campylobacteriosis

X Mumps X Cancer (execpt non-melanoma skin cancer, and including benign and borderline intracranial and CNS tumors) *3

6 months Neurotoxic shellfish

poisoning

X

Carbon monoxide poisoning

X

Pertussis X

Chancroid

X

Pesticide-related illness and injury X

Chlamydia

X Plague X X Chlamydia in pregnant women and neonates

X

Poliomyelitis, paralytic and non-paralytic

X X

Chlamydia in children <12 years of age *5

X

Psittacosis (Ornithosis) X

Cholera X X

Q Fever X Ciguatera fish poisoning (Ciguatera)

X

Rabies, animal X

Congenital anomalies*6

6 months Rabies, human

X

Conjunctivitis in neonates <14 days old

X

Rabies, possible exposure*18

X X Creutzfeld-Jakob disease (CID)*7

X

Ricin toxicity X X


Cryptosporidiosis

X

Rocky Mountain spotted fever X

Cyclosporiasis

X

Rubella, including congenital

X X

Dengue

X

St. Louis encephalitis (SLE) virus neuroinvasive and non-neuroinvasive disease

X

Diphtheria X X

Salmonellosis X Eastern Equine encephalitis virus neuroinvasive and non-neuroinvasive disease

X

Saxitoxin poisoning including Paralytic shellfish poisoning (PSP)

X

Ehrlichiosis/Anaplasmosis

X

Severe Acute Respiratory Syndrome-associated Coronavirus (SARS-CoV) disease

X X

Ehrlichiosis/Anaplasmosis-undetermined or unspecified

X

Shigellosis X

Encephalitis, other

X Smallpox X X

Enteric disease due to Escherichia coli O157:H7

X

Staphylococcus aureus - community associated mortality*19

X

Enteric disease due to other pathogenic Escherichia coli*8

X

Staphylococcus aureus with intermediate or full resistance to vancomycin (VISA,VRSA)

X

Giardiasis (acute)

X

Staphylococcus enterotoxin B X

Glanders X X

Streptococcal disease, invasive, Group A X

Gonorrhea

X


Gonorrhea in children < 12 years of age*5

X

Streptococcus pneumoniae, invasive disease in children < 5 years, drug sensitive and resistant

X

Gonorrhea in pregnant women and neonates

X

Syphilis X Gonorrhea (Antibotic Resistant)

X

Syphilis in pregnant women and neonates X

Granuloma Inguinale

X Tetanus X Haemophilus influenzae, meningitis and invasive disease X X

Toxoplasmosis, acute

X

Hansen disease (Leprosy)

X

Trichinellosis (Trichinosis) X

Hantavirus infection

X

Tuberculosis (TB) *24 X Hemolytic uremic syndrome

X

Tularemia X X

Hepatitis A*10

X

Typhoid fever X Hepatitis B, C, D, E and G Virus*10

X

Typhus fever (outbreak)

X X

Hepatitis B surface antigen (HBsAg)-positive in a pregnant woman or a child up to 24 months old

X

Typhus fever (endemic)

X

Herpes simplex virus (HSV) in infants up to 60 days old with disseminated infection with involvement of liver, encephalitis and infections limited to skin, eyes and mouth*11

X

Vaccinia disease

X X

HSV – anogenital in children < 12 years of age*5*11

X

Varicella (ChickenPox) *25 X

Human immunodeficiency virus (HIV)

2 weeks Varicella mortality

X


Human immunodeficiency virus (HIV) Exposed Newborn –infant < 18 months of age born to a HIV infected woman

X

Venezuelan equine encephalitis virus neuroinvasive and non-neuroinvasive

X X

Human papillomavirus (HPV) associated laryngeal papillomas or recurrent respiratory papillomatosis in children <6 years of age*5

X

Vibriosis (Vibrio infections, other than Cholera)

X

HPV – anogenital in children <12 years of age*5

X

Viral hemorrhagic fevers

X X

Influenza due to novel or pandemic strains

X X

West Nile virus neuroinvasive and non-neuroinvasive disease

X

Influenza-associated pediatric mortality in persons aged < 18 years

X

Western equine encephalitis virus neuroinvasive and non-neuroinvasive disease

X

Lead poisoning*16

X Yellow fever X X Legionellosis

X

Leptospirosis

X


SUBJECT: REPORTABLE DISEASES TENNESSEE Page 1 of 3 ISSUE DATE: June 30, 2002 Policy No. IC-03T REVIEW/REVISION DATE: March 31, 2014 PROGRAM: All Programs POLICY: It is the policy of RHG to report all infections, and contagious or communicable diseases to appropriate county and/or state health department officials. PROCEDURES: Should a resident or employee be suspected of or diagnosed as having any of the following diseases, it shall be promptly reported to the Nurse Manager, who will then notify appropriate county and/or State Health Department officials. The diseases and events listed below are declared to be communicable and/or dangerous to the public and are to be reported to the local health department by all hospitals, physicians, laboratories, and other persons knowing of or suspecting a case in accordance with the provision of the statutes and regulations governing the control of communicable diseases in Tennessee (T.C.A. §68 Rule 1200-14-01-.02). The potential or suspect cases of disease might be based on a positive laboratory test, clinical symptoms, or epidemiologic criteria. Public health investigations are usually conducted to determine and implement appropriate public health interventions. Category 1A: Requires immediate telephonic notification (24 hours a day, 7 days a week), followed by a written report using the PH-1600 within 1 week. [002] Anthrax (Bacillus anthracis)B

[005] Botulism-Foodborne (Clostridiumbotulinum)B

[004] Botulism-Wound (Clostridium botulinum) [505] Disease Outbreaks (e.g., foodborne, waterborne, healthcare, etc.) [023] Hantavirus Disease [096] Measles-Imported [026] Measles-Indigenous [095] Meningococcal Disease (Neisseria meningitidis) [516] Novel Influenza A [032] Pertussis (Whooping Cough) [037] Rabies: Human [112] Ricin PoisoningB

[132] Severe Acute Respiratory Syndrome (SARS) [107] SmallpoxB

[110] Staphylococcal Enterotoxin B (SEB) Pulmonary PoisoningB

[111] Viral Hemorrhagic FeverB


Category 1B: Requires immediate telephonic notification (next business day), followed by a written report using the PH-1600 within 1 week. [006] Brucellosis (Brucella species)B

[502] Burkholderia mallei infectionB

[010] Congenital Rubella Syndrome [011] Diphtheria (Corynebacterium diphtheriae) [123] Eastern Equine Encephalitis Virus Infection [506] Enterobacteriaceae, Carbapenem-resistant [507] Francisella species infection (other than F. tularensis)B

[053] Group A Streptococcal Invasive Disease (Streptococcus pyogenes) [047] Group B Streptococcal Invasive Disease (Streptococcus agalactiae) [054] Haemophilus influenzae Invasive Disease [016] Hepatitis, Viral-Type A acute [513] Influenza-associated deaths, age <18 years [520] Influenza-associated deaths, pregnancyassociated [515] Melioidosis (Burkholderia pseudomallei) [102] Meningitis-Other Bacterial [031] Mumps [033] Plague (Yersinia pestis)B

[035] Poliomyelitis-Nonparalytic [034] Poliomyelitis-Paralytic [119] Prion disease-variant Creutzfeldt Jakob Disease [109] Q Fever (Coxiella burnetii)B

[040] Rubella [041] Salmonellosis: Typhoid Fever (Salmonella Typhi) [131] Staphylococcus aureus: Vancomycin nonsensitive – all forms [075] Syphilis (Treponema pallidum): Congenital [519] Tuberculosis, confirmed and suspect cases of active disease (Mycobacterium tuberculosis complex) [113] Tularemia (Francisella tularensis)B

[108] Venezuelan Equine Encephalitis Virus InfectionB

Category 2: Requires written report using form PH-1600 within 1 week. [501] Babesiosis [003] Botulism-Infant (Clostridium botulinum) [121] California/LaCrosse Serogroup Virus Infection [007] Campylobacteriosis (including EIA or PCR positive stools) [503] Chagas Disease [069] Chancroid [055] Chlamydia trachomatis-Genital [057] Chlamydia trachomatis-Other [009] Cholera (Vibrio cholerae) [001] Cryptosporidiosis (Cryptosporidium species) [106] Cyclosporiasis (Cyclospora species) [504] Dengue Fever [522] Ehrlichiosis/Anaplasmosis – Any [060] Gonorrhea-Genital (Neisseria gonorrhoeae) [064] Gonorrhea-Ophthalmic (Neisseria gonorrhoeae)


BPossible Bioterrorism Indicators Effective 01/01/2012. Updated 02/03/2012. [061] Gonorrhea-Oral (Neisseria gonorrhoeae) [062] Gonorrhea-Rectal (Neisseria gonorrhoeae) [133] Guillain-Barré syndrome [058] Hemolytic Uremic Syndrome (HUS) [480] Hepatitis, Viral-HbsAg positive infant [048] Hepatitis, Viral-HbsAg positive pregnant female [017] Hepatitis, Viral-Type B acute [018] Hepatitis, Viral-Type C acute [021] Legionellosis (Legionella species) [022] Leprosy [Hansen Disease] (Mycobacterium leprae) [094] Listeriosis (Listeria species) [024] Lyme Disease (Borrelia burgdorferi) [025] Malaria (Plasmodium species) [521] Powassan virus infection [118] Prion disease-Creutzfeldt Jakob Disease [036] Psittacosis (Chlamydia psittaci) [105] Rabies: Animal [122] St. Louis Encephalitis Virus Infection [042] Salmonellosis: Other than S. Typhi (Salmonella species) [517] Shiga-toxin producing Escherichia coli (including Shiga-like toxin positive stools, E. coli O157 and E. coli non-O157) [043] Shigellosis (Shigella species) [039] Spotted Fever Rickettsiosis (Rickettsia species including Rocky Mountain Spotted Fever) [130] Staphylococcus aureus: Methicillin resistant Invasive Disease [518] Streptococcus pneumoniae Invasive Disease (IPD) [074] Syphilis (Treponema pallidum): Cardiovascular [072] Syphilis (Treponema pallidum): Early Latent [073] Syphilis (Treponema pallidum): Late Latent [077] Syphilis (Treponema pallidum): Late Other [076] Syphilis (Treponema pallidum): Neurological [070] Syphilis (Treponema pallidum): Primary [071] Syphilis (Treponema pallidum): Secondary [078] Syphilis (Treponema pallidum): Unknown Latent [044] Tetanus (Clostridium tetani) [045] Toxic Shock Syndrome: Staphylococcal [097] Toxic Shock Syndrome: Streptococcal [046] Trichinosis [101] Vancomycin resistant enterococci (VRE)Invasive Disease [114] Varicella deaths [104] Vibriosis (Vibrio species) [125] West Nile virus Infections-Encephalitis [126] West Nile virus Infections-Fever [124] Western Equine Encephalitis Virus Infection [098] Yellow Fever [103] Yersiniosis (Yersinia species)


Category 3: Requires special confidential reporting to designated health department personnel within 1 week. [500] Acquired Immunodeficiency Syndrome (AIDS) [512] Human Immunodeficiency Virus (HIV) [525] All CD4+ T-cell and HIV-1 Viral Load testing results from those laboratories performing these tests Category 4: Laboratories and physicians are required to report all blood lead test results within 1 week. [514] Lead Levels (blood) Category 5: Events will be reported monthly (no later than 30 days following the end of the month) via the National Healthcare Safety Network; Clostridium difficile infections (Davidson County residents only) will also be reported monthly to the Emerging Infections Program (EIP). [523] Healthcare Associated Infections, Catheter Associated Urinary Tract Infections [508] Healthcare Associated Infections, Central Line Associated Bloodstream Infections [509] Healthcare Associated Infections, Clostridium difficile [524] Healthcare Associated Infections, Dialysis Events [510] Healthcare Associated Infections, Methicillin resistant Staphylococcus aureus positive blood cultures [511] Healthcare Associated Infections, Surgical Site Infections Items in purple are identified zoonotic diseases of horses, goats, cats, rabbits and swine


SUBJECT: NEEDLE STICKS & CUTS Page 1 of 1 ISSUE DATE: June 30, 2002 Policy No. IC-04 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: ALL POLICY: It is the policy of RHG that all personnel take precautions to prevent injuries caused by needle sticks, sharps, or other instruments or devices and to report all incidents that occur. PROCEDURE: 1. Caution must be exercised when handling used needles, sharp blades, or other sharp objects or devices

to reduce the possibility of needle stick injuries and/or cuts. 2. To aid in preventing needle stick injuries, needles shall not be recapped, purposely bent or broken by

hand, removed from disposable syringes, or otherwise manipulated by hand. 3. Used needles and other sharp objects must be placed in a puncture resistant container located in the

staff office. 4. All personnel must report needle stick injuries and cuts to their supervisor at the time of the

occurrence and an Incident Report and Needle Stick log must be completed. 5. Staff will be sent to Emergency/urgent care for appropriate follow up and testing. 6. Key procedural points when using needles or sharps:

A. Wash your hands thoroughly before beginning, and after the procedure. B. Use protective equipment as indicated. C. Use caution when handling used needles and syringes. D. To minimize the risk of a needle stick injury, keep the puncture resistant container as close to

the work area as practical. E. Gloves must be worn when handling blood specimens, body fluids, excretions, as well as

surfaces, materials, and objects exposed to them.


SUBJECT: UNIVERSAL PRECAUTIONS CATEGORY I AND II TASKS Page 1 of 5 ISSUE DATE: June 30, 2002 Policy No. IC-05 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: All Programs POLICY: It is the policy of RHG for all staff performing Category I and II tasks to participate in an initial and annual training program. PROCEDURES: 1. Orientation and annual in-service training programs are conducted to provide all personnel who

perform Category I an II tasks with information concerning standard operating procedures, work practices, and protective equipment for each task performed.

2. Personnel will not be permitted to perform a Category I or II task until such training has been

completed. 3. Each employee who is required to perform Category I and II tasks shall undergo an initial and annual

training program. Our training program includes:

a. The modes of transmission of AIDS (HIV) and Hepatitis B (HBV) viruses.

b. How to recognize and differentiate Category I and II tasks.

c. Instructions on types of protective clothing and equipment generally appropriate for Category I and II tasks, as well as instructions on the basis for selecting the clothing and equipment.

d. Instructions on the actions to take and persons to contact if unplanned Category I tasks are

encountered.

e. Instruction on where protective clothing and equipment is kept, how to use it, and how to remove, handle, decontaminate, and dispose of contaminated clothing or equipment.

f. Instruction on the limitation of protective clothing and equipment. g. Instruction on the corrective action to take in the event of spills or personnel exposure to

fluids or tissue, the appropriate reporting procedures, and the medical monitoring recommended in cases of suspected parenteral exposure.

4. Training records, indicating the dates of each training session, the contents of each session, the names

of all persons attending the session, and the name(s) of the person(s) conducting the class shall be maintained for a minimum of three (3) years. A copy of the "Record of Training" form is located in the individual employee Human Resource file.


5. To ensure staff have access to appropriate precautions, the Policy and Procedure Manual, including

the Infection Control Section, is available online. 6. Inquiries concerning Universal Precautions should be directed to the Nurse Manager.

Infection Definitions

Nosocomial infection Nosocomial infections are infections acquired directly or indirectly in a medical setting. The probability of a microorganism causing infection in a host is dependent upon the dose (number of microorganisms), a receptive host site of contact with the organism, time of contact (sufficient for multiplication or not) and the virulence of the organism.

Routes of transmission • Direct contact transmission involves direct physical transfer of microorganisms from an infected or

colonized person to a susceptible host. Indirect contact transmission involves the contact of a susceptible host with a contaminated inanimate object, such as contaminated instruments or equipment.

• Droplets are generated during coughing, sneezing, talking, and during certain procedures such as suctioning and bronchoscopy. Transmission occurs when droplets containing microorganisms come in contact with the conjunctiva, nasal mucosa or mouth of a susceptible person.

• Airborne transmission occurs by dissemination in the air of either droplet nuclei or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed via air currents and can remain airborne for long periods before being inhaled by the susceptible host.

• Vehicle transmission applies to microorganisms transmitted by contaminated food, water, drugs, blood or body fluids.

• Vector borne transmission occurs when mosquitoes, flies, rats or other vermin transmit microorganisms

Controlling Infection Sources

Autogenous Sources: Self-infection from the normal organisms in or on the person himself. Human Sources: All humans are potential reservoirs of infectious disease organisms that can be transmitted to a susceptible host. Environmental Sources: An indirect means of transmission. Some microbes can survive for relatively long periods in an inanimate environment. Ingestible Vehicles: Ingestible materials, such as food, water, and milk can be considered infectious disease sources.


EXPOSURE CATEGORIES/JOB CLASSIFICATION Exposure Categories Category I. Tasks that involve exposure to blood, body fluids, or other infectious materials. All procedures or other job-related tasks that involve an inherent potential for membrane or skin contact with blood, body fluids, or other infectious materials, or a potential for spills or splashes of them, are Category I tasks. Use of appropriate protective measures should be required for every employee engaged in Category I tasks. Category II. Tasks that involve no exposure to blood, body fluids or other infectious materials, but employment may require performing unplanned Category I tasks. The normal work routine involves no exposure to blood, body fluids, or other infectious materials, but exposure or potential exposure may be required as a condition of employment. Appropriate protective measures should be readily available to every employee engaged in Category II tasks. Category I Tasks: Tasks that involve exposure to blood, body fluids or tissue but that may require performance of tasks involving exposure either unexpectedly or on short notice. These would include linen changes and/or emergency first aid. Employees: Nurse Manager, Nurse Category II Tasks: Involve no exposure to blood, body fluids or tissues, but employment may require performing unplanned Category I tasks. Employees: Executive Administrator, Referral & Admissions Staff, Grounds Keeping, Facility & Fleet Manager, Administrative Office staff, Interns or Volunteers, Psychotherapist, Residential Care Coordinator, TLLC staff, Animal Assisted Therapy Staff, Culinary Staff Protection: Protective equipment will be readily accessible for use on short notice


1. Hand Washing

a. Hands will be washed before and after performing any clean or sterile invasive procedure, eating or preparing food, or touching residents. b. Hands will be washed after any direct contact with blood, body fluids, or other potentially infectious materials; handling soiled linen or waste; handling devices or equipment soiled with blood or body fluids; contact with an open wound or drainage; specimen collection; removal of gloves; and after using the toilet.

2. Disposal of Contaminated Sharps and Regulated Waste

a. Contaminated needles will not be bent, recapped, or removed from the syringe after use. An FDA-approved sharps destruction device is the only method acceptable for the destruction of contaminated needles. b. All other sharp instruments or devices used for invasive procedures will be placed in an FDA approved puncture resistant contaminated sharps container immediately after use. c. Contaminated sharps containers are readily accessible to employees, located in the nurse’s station and maintained in an upright and secure position throughout use. d. Disposable contaminated sharps containers will be closed and replaced when 3/4 full to prevent protrusion of contents. e. Disposal of all regulated waste will be in accordance with all applicable federal and state regulations.

3. Work Area Restrictions a. Eating, drinking, applying cosmetics or lip balm, handling contact lenses or storage of food items is not permitted in any area where contaminated items are handled or stored, or in work areas where there is a reasonable likelihood of occupational exposure to bloodborne pathogens. b. Food, drink, or food serving items will be stored in refrigerators, freezers, or cabinets or stored on shelves, countertops, or other work spaces separate from those where blood and/or other potentially infectious materials are present. c. All procedures involving blood or other potentially infectious materials will be performed in such a manner as to minimize splashing, spraying, spattering and/or from generating droplets of these substances.

4. Personal Protective Equipment (PPE) consists of items such as gloves, masks, and gowns. PPE eliminates or minimizes exposure to bloodborne pathogens. This equipment is provided at no cost to the employee.

a. The employee will use PPE when contact with blood, body fluids, mucous membranes, or other potentially infectious material can be reasonably anticipated. PPE is not needed when contact only involves intact skin or sweat. b. PPE will be readily accessible and available in appropriate sizes at the employee work station or work site. c. The facility will repair or replace any personal protective equipment as needed to maintain its effectiveness.

Gloves a. Disposable gloves will be worn when it can be reasonably anticipated that the employee may have direct contact with blood or other potentially infectious material, mucous membranes, soiled laundry and non-intact skin.


b. Disposable gloves will be discarded immediately after use.

c. Disposable gloves will be worn when handling regulated waste, during blood spill, cleanup, and during decontamination of potentially infectious materials.

Disposable Gowns a. Impervious fluid-resistant gowns, aprons, and other protective body clothing will be worn by any employee who can reasonably anticipate an exposure to blood, body fluids, or other potentially infectious material.


SUBJECT: INFECTION CONTROL REPORTING Page 1 of 1 ISSUE DATE: June 30, 2002 POLICY NO. IC-06 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: ALL

POLICY: It is the policy of RHG to detect and record all infectious diseases that occur in every program and every area of the facility and to identify potential infection problems in specific areas and to evaluate the results and trends and make reports and recommendations for appropriate follow-up. PROCEDURES: 1. The Infection Control Report form is located at each nurse's station. 2. The report is to be completed by a licensed nurse when any resident or staff exhibits

symptoms of an infectious disease. The following is a list of possible symptoms:

A. Abnormal finding of physical examination (i.e., redness, swelling, rashes, lice, etc.)

B. Laboratory studies suggestive of infection. C. Temperature elevation above 100o orally, 101o rectally. D. Any employee in bed 24 hours with suspicion of medical/infectious problems. E. Nausea, vomiting, diarrhea of continuous or severe nature. F. History of hepatitis, VDRL, TB within the past year. G. Purulent wound or skin infection. H. Draining lesions. I. Abnormal discharge from any orifice. J.. Positive mantoux/positive chest X-ray.

3. The form is to be completed by the Nurse when any resident or staff presents with

reportable infections signs or symptoms. 4. The Nurse Manager will review the report and the copies will be made available to the

Risk Manager. 5. Reportable diseases will be reported to the appropriate local and state authorities by the

Nurse Manager within the timeframes required.


SUBJECT: RESIDENT AND STAFF T.B. TESTING Page 1 of 1 ISSUE DATE: March 31, 2004 Policy No. IC-07 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: ALL STANDARD: State Health Departments maintain a tuberculosis registry of all persons in their jurisdiction with current TB. POLICY: The Nurse Manager coordinates the facility's program to control the transmission of T. B. All residents presenting for admission will be required to complete a T.B. test. All new hire staff will be required to complete a T. B. test as part of their new employee physical. PROCEDURES:

1. All residents and staff will be required to receive T.B. testing through RHG and/or a referred provider.

2. The result will become part of the resident’s chart or in the case of staff, their HR file.

3. Individuals who present with a positive Mantoux test will be required to receive a chest x-ray. Employees must present a negative chest x-ray prior to returning to work. To treat or not treat with medication is the decision of the treating physician or designee. Residents with a positive Mantoux test will be referred to a physician for treatment.

4. If a resident or staff had a positive Mantoux test in the past, a TB symptom questionnaire will be completed and reviewed by the Infection Control designee. The Infection Control designee may recommend treatment and follow up with primary care physician.

5. Staff and Residents will complete the Annual TB Screening Questionnaire to determine if further testing needs to be completed.


SUBJECT: RESIDENT AND STAFF TETANUS VACCINES Page 1 of 1 ISSUE DATE: March 31, 2012 Policy No. IC-08 REVIEW/REVISION DATE: March 31, 2014 PROGRAM: SML POLICY: In an effort to reduce staff and resident risk of infectious diseases associated with animal care and boarding, RHG will offer tetanus vaccines. Any staff or resident that participates in services or cares for animals at the equine facility, will be offered a tetanus vaccine if they are not current. PROCEDURES:

1. All residents and staff will be offered a tetanus vaccine prior to participating in animal care or services at the equine facility.

2. Resident Tetanus vaccines will be documented in the electronic record by the administering nurse.

3. Staff Tetanus vaccines will be documented and placed in their Human Resource file.


SUBJECT: Resident and Staff Influenza Prevention Page 1 of 2 ISSUE DATE: March 31, 2013 Policy No. IC-09 REVIEWED/REVISION DATE: April 23, 2014 PROGRAM: ALL POLICY: All employees of RHG shall be provided the influenza vaccine during the annual influenza vaccination campaign. Employees will be required to obtain vaccination by December 1 of each calendar year or sign a declination. Records will be maintained documenting vaccinations and declinations. If vaccine shortages occur or if CDC recommendations are altered, the (Medical Director and/or Clinical Director) may suspend or revoke all or part of this policy. PURPOSE: RHG recognizes its responsibility to provide employees a workplace free of recognized hazards. This policy is intended to maximize vaccination rates against influenza among personnel. The goal is to protect resident, employees, interns, students and others affiliated with RHG.. Annual influenza vaccination has been found to be both safe and effective in reducing the risk of influenza and health-care related transmission. PROCEDURE: 1. RHG will offer the influenza vaccine to all residents and new admissions free of charge at the

beginning and during the influenza season based on vaccine availability and published CDC guidelines.

2. All employees will be required to obtain the influenza vaccine or sign the declination on the Influenza

Vaccination/Waiver each year by December 1st to the Nurse Manager or Human Resource Representative. Completed forms will become part of the employee Human Resource file.

3. RHG will make available the location and phone number of the local health department, providers

participating in the health insurance plan available to RHG full time employees and offer low cost influenza vaccine to employees at their expense.

4. The Nurse Manager will note track approved exceptions and accommodate for these exceptions in

annual goals and reporting. Approved exceptions are as follows: Medical: Staff may decline due to severe allergy to the vaccine or components or Guillain-Barre within six weeks of a prior influenza vaccine. Individuals requesting a medical exception are required to complete the Influenza Declination Form with this reason noted and return it to Human Resources and/or the Nurse Manager. Religious: Staff may decline due to sincerely held religious beliefs. Individuals requesting a religious exception are required to complete the Influenza Declination Form with this reason noted and return it to Human Resources and/or the Nurse Manager.


5. The Nurse Manager will track all potential influenza cases in staff and residents and consult with the

local health department for updates.

TN ANNUAL GOALS Year Goal How to Achieve Results Adjustment 2014 Assess rate of

vaccination Track declinations 30% Offer free

vaccine 2015 40% Offer vaccinations

free to staff

2016 50% 2017 60% 2018 70% 2019 80% 2020 90%

FL ANNUAL GOALS

Year Goal How to Achieve Results Adjustment 2014 Assess rate of

vaccination Track declinations 10% Offer free

vaccine 2015 40% Offer vaccinations

free to staff

2016 50% 2017 60% 2018 70% 2019 80% 2020 90%


SUBJECT: HAND HYGENINE AND RESPIRATORY ETTIQUETTE Page 1 of 2 ISSUE DATE: June 30, 2002 Policy No. IC-10 REVIEWED/REVISION DATE: March 31, 2014 PROGRAM: ALL POLICY: Hands are to be washed thoroughly with friction, soap and water for 15 seconds before handling or serving food, after using the toilet, smoking or eating, coughing or sneezing, touching hair or face, before and after handling raw poultry or meat, touching soiled objects or clothing, before and after providing resident care, before and after handling animals or contaminating hands in any way that common sense dictates the need for hand washing. Hands are not to be washed in food preparation sink. PROCEDURE: 1) Wet hands and forearms thoroughly, 2) Add soap and work up lather for at least 10-15 seconds. Use friction, wash entire surface of hands for

at least 15 seconds. Wash well between fingers and around and under fingernails, 3) Rinse with hands lowered to allow soiled water to drain directly into sink. Do not allow hands to

touch sink. 4) Dry hands well, especially between fingers. 5) Use disposable hand towels to turn off sink. 6) Hands will be washed before and after performing any clean or sterile invasive procedure, eating or

preparing food, or touching residents. 7) Hands will be washed after any direct contact with blood, body fluids, or other potentially infectious

materials; handling soiled linen or waste; handling devices or equipment soiled with blood or body fluids; contact with an open wound or drainage; specimen collection; removal of gloves; and after using the toilet.

8) To prevent the spread of infectious diseases through airborne transmission, staff and residents will be

educated on respiratory etiquette; coughing or sneezing into one’s shoulder and not their hands. 9) Hands should be washed:

• When arriving to work • After going to the bathroom • Before, during and after meal preparation • Before eating


• After blowing your nose, sneezing or coughing • After providing personal care • After gardening, housework • Whenever hands are visibly dirty • Before and after administering medications to an individual • First thing in the morning and last thing at night

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