Regulations for an
Infection Prevention and
Control Program
2014 FUNDAMENTALS
OCTOBER 29 - 31, 2014
ROXANNE PERRY, RN, MS
MANAGER
INTEGRATED PROGRAMS MANAGEMENT SECTION
1
Department of Community Health

Medical Services Administration

Bureau of Medicaid Policy and Health Systems

Integrated Care Division

Integrated Programs Management Section
2
Objectives

List at least 3 purposes for developing an
effective infection prevention and control
program.

List and describe Federal and State Infection
Prevention & Control Regulations for different
types of health care facilities.
3
Historical Events

306-337 AD: Constantine the Great

1843: Oliver Wendell Holmes

1846: Ignaz Semmelweis

1860: Louis Pasteur

1867: Joseph Lister
4
Historical Events

1800’s: Florence Nightingale
1837 – Committed herself to nursing
1845 – Entered nursing – cared for poor/indigent
population
1851 – Official training/nursing career
5
Historical Events
1854 – Crimean War – cleaned hospital
equipment and reorganized
patient care
1855 – Concluded that hospital deaths
were due to poor living conditions

1950’s: Staphylococcal era

1959:
First Infection Control Nurse
6
Historical Events

Change from Universal Precautions to Standard
Precautions

Isolation Practices – least restrictive

Hepatitis B Vaccine

HIV/AIDS
7
Historical Events

MSIPC from MSIC

Influenza Vaccine

Pneumococcal Vaccine
8
Why have an Infection
Prevention & Control Program?

Prevent and protect residents, employees,
volunteers & visitors from infections

Maximize quality of care

Avoid legal issues

Avoid adverse publicity

Comply with regulations and accreditation
9
10
Regulations/Guidelines for the
Prevention & Control of Infections

Federal Government
Centers for Medicare and Medicaid
Services (CMS)
Center for Disease Control (CDC)
Occupational Safety and Health
Administration (OSHA)
11
Regulations/Guidelines for the
Prevention & Control of Infections

State Government
Michigan Public Health Code
Licensing Rules
Communicable Disease Rules
Medical Waste Regulatory Program
MIOSHA
12
Regulations/Guidelines for the
Prevention & Control of Infections

Accreditation Entities

Association for Professionals in Infection
Control and Epidemiology
13
Federal and State Regulations

Long Term Care – State and Federal

ICF/MR - Federal

Acute Care – State and Federal

CLIA Laboratories – State/Federal
14
Federal and State Regulations

Home Health – Federal

Ambulatory Surgical Clinics(ASC)/Freestanding
Surgical Outpatient Facilities(FSOF) – State and
Federal

End Stage Renal Disease - Federal
15
Federal and State Regulations

Outpatient Physical/Speech Therapy CentersFederal
Rural Health Clinics – Federal

Critical Access Hospitals – State and Federal

Comprehensive Outpatient Rehab Facilities Federal

16
Federal and State Regulations

Portable X-Ray Units – Federal

Hospice Residences – State and Federal

Hospice Agencies– State and Federal

Psychiatric Hospitals- State and Federal
17
Long Term Care Infection
Prevention/Control
Federal Regulations
18
Long Term Care Infection
Prevention/Control
F441
§483.65 Infection Control
 The facility must establish and maintain an
Infection Control Program designed to provide a
safe, sanitary and comfortable environment and
to help prevent the development and
transmission of disease and infection.
19
Long Term Care Infection
Prevention/Control
F441 continued

§483.65(a) Infection Control Program

§483.65(b) Preventing Spread of Infection

§483.65(c) Linens
20
Long Term Care Infection
Prevention/Control
F334
§483.25(n) Influenza and pneumococcal
immunizations-- (1) Influenza. The facility must develop policies
and procedures that ensure that—
 (2) Pneumococcal disease. The facility must
develop policies and procedures that ensure
that—
21
Long Term Care Infection
Prevention/Control
F281
483.20(k)(3)
The services provided or arranged by
the facility must—
(i) Meet professional standards of quality...
22
Long Term Care Infection
Prevention/Control
F520
483.75(o) Quality Assessment and Assurance
(1) A facility must maintain a quality assessment
and assurance committee consisting of(i)
The director of nursing services;
(ii)
A physician designated by the facility;
And
(iii)
At least 3 other members of the
facility’s staff.
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Long Term Care Infection
Prevention/Control
F520 continued
(2) The quality assessment and assurance
committee(3) State or the Secretary may not require
disclosure of the records of such committee
except insofar as such disclosure is related
to the compliance of such committee with the
requirements of this section.
(4) Good faith attempts by the committee to
identify and correct quality deficiencies will
not be used as a basis for sanctions.
24
Long Term Care Infection
Prevention/Control
F520 continued
Summary
 Identifies quality issues
 Establishes protocols
 Develops and implements corrective
actions
 Evaluate response
25
Long Term Care Infection
Prevention/Control
Michigan Licensure Regulations
26
Michigan Licensure Regulation
Rule 507
R 325.20507 Infection Control
 A written policy shall govern the control of
communicable disease and infections in
the nursing home and shall require the
establishment and operation of an
Infection Control Committee, which shall
include at least the director of nursing and
representatives of administration, dietary,
housekeeping, and maintenance services.
27
Michigan Licensure Regulation
Rule 402
R 325.20402
Health of Employees and Others Providing Care


An employee on duty in the home shall be in
good health and free from communicable
disease.
An employee shall have an intradermal test for
tuberculosis at the beginning of employment and
annually thereafter. If at any time the skin test is
positive, the local health department shall be
notified and the employee shall have a chest xray to determine the presence of disease.
28
Michigan Licensure Regulation
Rule 506
R 325.20506 Tuberculosis Testing

The facility shall develop and implement
policies governing the periodic intradermal
tuberculin testing of patients in addition to
the requirement for a chest x-ray on
admission.
29
Hospital Infection Prevention/Control
Federal Regulations
30
Hospital Infection Prevention/Control
A-0747
482.42 Condition of Participation: Infection Control
The hospital must provide a sanitary environment
to avoid sources and transmission of infections
and communicable diseases. There must be an
active program for the prevention, control, and
investigation of infections and communicable
diseases.
31
Hospital Infection Prevention/Control
A-0748
482.42(a) Standard: Organization and Policies
A person or persons must be designated
as infection control officers to develop and
implement policies governing control of
infections and communicable diseases….
32
Hospital Infection Prevention/Control
A-0748
482.42(a)(1) The infection control officer or officers
must develop a system for identifying, reporting,
investigating, and controlling infections and
communicable diseases of patients and
personnel.
33
Hospital Infection Prevention/Control
A-0749
482.42(a)…. The infection control officer or
officers must maintain a log of incidents
related to infections and communicable
diseases.
34
Hospital Infection Control
A-0756
482.42(b) Standard: Responsibilities of Chief
Executive Officer, Medical Staff, and Director of
Nursing Services
The chief executive officer, the medical staff,
and the director of nursing must—
35
Hospital Infection Control

(1) Ensure that the hospital-wide quality
assessment and performance improvement
(QAPI) program and training programs address
problems identified by the infection control
officer or officers; and

(2) Be responsible for the implementation of
successful corrective action plans in affected
problem areas.
36
Hospital Infection Prevention/Control
Michigan Licensure Regulations
(Minimum Standards for Hospitals)
37
Hospital Infection Prevention/Control

R 325.1021 (Rule 21)
Compliance with law and regulations

R 325.1022 (Rule 22)
Water and ice supply

R 325.1023 (Rule 23)
Sewage, garbage, and waste disposal
38
Hospital Infection Prevention/Control

R 325.1024 (Rule 24)
Laundering and sterilization of linens;
Sterilization of instruments and utensils

R 325.1025 (Rule 25)
Heating and ventilating
39
Hospital Infection Prevention/Control

R 325.1026 (Rule 26)
General maintenance.

R 325.1027 (Rule 27)
Patient Care.
40
Infection Control References
Federal Regulations
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107_Appe
ndixtoc.pdf
State Regulations
www.michigan.gov/bhcs
MSIPC
http://www.msipc.org/
41