Infection Prevention and Control: A Priority for 2025

?As we enter 2025, infection prevention and control continue to take center stage in the post-acute care landscape. With infection control deficiencies being one of the most frequently cited areas in 2024, the importance of a robust program cannot be overstated. According to preliminary data, over 12,000 F-tag 880 violations were cited in 2024, with approximately 15% reaching G-level (actual harm) and 3% escalating to Immediate Jeopardy (IJ) status. These numbers emphasize the urgent need for nursing homes to focus on compliance, safety, and proactive measures.

Why Infection Control Should Be a Focus

• Surveyor Scrutiny: Infection control has been a consistent focal point for surveyors due to its direct impact on resident and staff safety.
• High-Risk Area: Non-compliance with infection prevention measures can lead to outbreaks, resident harm, and substantial fines.
• Regulatory Guidance Updates: CMS and CDC continue to update their guidance, particularly around Enhanced Barrier Precautions (EBP) and outbreak management.

?Components of a Robust Infection Control Program

1. Policies and Procedures

Clear, detailed, and up-to-date infection prevention policies form the backbone of compliance. These should:

• Incorporate the latest CMS guidance and CDC best practices.
• Include specific protocols for Enhanced Barrier Precautions, MDROs, and outbreak management.
• Outline responsibilities for infection prevention at every staff level.

2. Education and Training

Ongoing education ensures all staff understand and can implement infection control measures effectively:

• Initial and Annual Training: Cover topics like hand hygiene, PPE use, outbreak response, and EBPs.
• Demonstrations and Competency Checks: Staff should perform return demonstrations to confirm understanding.
• Real-Life Scenarios: Include mock drills for outbreaks to prepare staff for potential emergencies.

3. Accessibility of PPE and Resources

Readily available resources are essential for compliance:

• PPE Stations: Ensure gloves, gowns, masks, and hand hygiene supplies are accessible in all required locations.
• Signage: Post clear instructions for infection prevention measures outside resident rooms.

4. Leadership and Accountability

A strong infection control program needs effective leadership:

• Designate a dedicated Infection Preventionist (IP) to oversee policies, conduct audits, and provide training.
• Hold leadership and staff accountable for consistent adherence to protocols.

5. Monitoring and Audits

Regular monitoring is key to maintaining compliance:

• Conduct daily audits of infection control practices, focusing on high-risk areas like hand hygiene and PPE use.
• Use tracking tools to monitor infection rates, PPE usage, and compliance trends.

6. Documentation

Surveyors expect detailed documentation of infection control efforts:

• Maintain logs of training sessions, audits, and corrective actions.
• Keep records of infection surveillance and outbreak responses.

Case Study: Safe Care Nursing Home

Safe Care Nursing Home faced Immediate Jeopardy (IJ) in 2024 due to failures in infection prevention measures, specifically around Enhanced Barrier Precautions.

What Went Wrong?

• Staff were unaware of the requirements for EBPs, particularly for residents colonized with MDROs.
• PPE use was inconsistent during high-contact activities like bathing, wound care, and toileting.
• Inadequate signage and missing PPE stations led to confusion and non-compliance.

The Impact: A preventable outbreak of MDROs affected multiple residents, resulting in surveyors issuing an IJ citation under F880.

Plan of Correction Safe Care implemented a rigorous Plan of Correction to address these deficiencies:

1. Policy Revisions: Infection control policies were updated to include specific EBP protocols.
2. Mandatory Training: All staff completed training on EBPs, MDROs, and proper PPE use, with competency evaluations.
3. PPE Access and Signage: PPE stations were installed outside resident rooms, with clear signage to guide staff.
4. Daily Monitoring: Leadership conducted daily PPE audits and staff observations to ensure compliance.
5. Infection Control Leadership: A new Infection Preventionist was hired to lead ongoing efforts.

Outcome: Within 30 days, the Immediate Jeopardy status was lifted, and the facility demonstrated sustainable improvements during the follow-up survey.

Call to Action: Proactive Infection Control

Safe Care’s experience highlights the importance of prioritizing infection prevention measures. Don’t wait for surveyors to identify gaps—take proactive steps today:

1. Audit Your Facility: Conduct a comprehensive infection control audit to identify vulnerabilities.
2. Update Your Policies: Align your infection prevention policies with the latest CMS and CDC guidance.
3. Enhance Training Programs: Provide ongoing education and competency checks for all staff.
4. Strengthen Leadership: Ensure your Infection Preventionist has the tools and authority to lead effectively.

Resources to Strengthen Your Program

• CDC Guidelines: Comprehensive infection control resources and EBP guidance. Visit CDC Infection Control
• CMS Infection Control Toolkit: Policies and best practices for compliance.
• APIC (Association for Professionals in Infection Control and Epidemiology): Training and certification programs for Infection Preventionists.
• NHSN (National Healthcare Safety Network): Infection tracking and surveillance tools.

Start 2025 with a commitment to safety and compliance. For expert guidance, audits, or training materials, reach out to [email protected]

?Aysha Kuhlor MSN, RN, PAC-NE

Chief Clinical Advisor

Phone: 808-688-7459

Email: [email protected]

Website: www.theinspac.com

Courses: https://courses.theinspac.com- explore our courses and certifications

Linktree: https://linktr.ee/theinspac to book an appointment

Contact: [email protected]

?Together, let’s make 2025 a year of proactive infection control and quality care.

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