Long-Term Care Survey Alert

Tip: Don’t overdo the antibiotic bit; instead pay closer heed to basics.

The stakes are about to rise in the fight against infectious disease in long-term care facilities — and to avoid federal scrutiny providers will have to transition quickly to new ways of thinking about everything from dirty linen to antibiotics.

Consider the news coming out of Washington in just the past few months. This past summer, the Centers for Medicare & Medicaid Services (CMS) proposed a major overhaul of nursing home regulations in its expansive Reform of Requirements for Long-Term Care Facilities, (CMS-3260-P).  Years in the making, the proposed rule includes an entire section devoted to infection control (§ 483.80). Soon after, the Centers for Disease Control and Prevention (CDC) sharpened the feds’ focus on infection control, issuing a nursing home-specific guide to antimicrobial stewardship that dovetails with CMS’s proposed rule and its many requirements regarding infection control.

Background: Washington’s buzz about improving infection control in nursing homes began in early 2014, when the CDC launched its infection control website for nursing homes and assisted living facilities (http://www.cdc.gov/longtermcare/). Since its launch, the site has evolved to include a plethora of resources on topics including CDC expert testimony, a round-up of fact sheets and other guides from groups including AMDA, the American Geriatrics Society, and the American Urological Association (AUA), and now the new related document from the CDC, Core Elements of Antibiotic Stewardship for Nursing Homes.

To get ready for the focus on infection control, take these steps now:

Read The Fine Print

The comment period on the proposed nursing home survey rule has passed (comments were due in September), but reading the proposed rule, especially its daunting section on infection control, is still well worth your time.

Key provisions include a requirement that facilities appoint a dedicated Infection Prevention and Control Officer (IPCO). Many experts are concerned that the requirements as proposed put a significant burden on nursing homes, especially smaller facilities and those caught off guard.

“The capability of a facility meeting the proposed regulation for each facility to have a dedicated IPCO is of concern for a number of reasons — and that goes without addressing the project cost being associated with the position in the first year,” opines Linda Elizaitis of CMS Compliance Group in New York City. Specifically, depending on how CMS refines the now-vague skill set for such an employee, simply finding a qualified individual will be daunting, especially for smaller and rural facilities, she says.

In its comments to CMS, for example, the Association for Professionals in Infection Control and Epidemiology (APIC) urges the agency to disallow a nurse with “basic” training in infection control from filling the IPCO shoes.

“Formal infection control training for an LTC IPCO must be based on the core competencies defined by APIC and the Certification Board of Infection Control and Epidemiology (CBIC) in order to maintain the high professional standards across the healthcare continuum,” the association states in its comments to CMS.

“We also note that the standard accepted term for a person with this level of training is ‘infection preventionist,’ and we recommend that CMS use this term instead of IPCO in order to ensure consistency across the infection prevention community and understanding of the level of training required to qualify for this duty,” the group adds.

Brush Up On the Basics

Given the feds’ ambitions, providers, even good ones, are going to have to step up their infection control game. And Elizaitis observes that, unfortunately, many facilities are still working toward full compliance on even the most basic infection control practices.

“Many facilities continue to have a difficult time with a number of infection control basics,” Elizaitis says, “such as hand washing techniques, soiled linen handling, and management of a resident who requires precautions.”

“When you look at a 2567 that includes a deficiency at F-441 and read that findings related to lack of hand washing or that a staff member was observed carrying soiled linen that was touching his or her uniform, it leads to genuine concerns regarding how the infection control program in the facility is being implemented and monitored,” Elizaitis cautions.

Undo Outdated UTI Protocols

A huge area of concern — and currently a source of survey woes — is the inappropriate use of antibiotics to treat urinary tract infections in nursing homes. Under the new regulations, you can be guaranteed even greater scrutiny, so be sure your practices are based on current evidence and recommendations.

For example, if signs and symptoms of urinary tract infection are not present, steer clear of antimicrobials for patients who have indwelling or intermittent catheterization of the bladder.

Best advice: According to the AUA, “Antibiotics in the absence of signs and symptoms … is not efficacious and risks inducing resistance to antimicrobials.”

Symptoms to look for before turning to antibiotics include fever; altered mental status or malaise with no other cause; flank or pelvic pain; flank or suprapubic tenderness; hematuria; dysuria, urinary urgency or frequency; and, in spinal cord injury patients, increased spasticity, autonomic dysreflexia or sense of unease.

“This applies to both indwelling and intermittent catheterization of the bladder,” the AUA advises. A major exception to the avoid antibiotics mindset: patients scheduled for a procedure or surgery may require peri-procedural antimicrobials.

 “Additionally, initial placement of a suprapubic tube requires a skin puncture or incision and, therefore, antibiotics should be considered,” the AUA notes.

Be Prepared

How quick will CMS finalize and phase in the new survey rules? It’s hard to predict how quickly CMS will move toward a final rule, but to play it safe, don’t count on a long lead time. Besides, getting serious about infection control now can serve you well by improving your record under the current survey requirement.

“We commend the intent of the proposed regulations, but we also know that compliance won’t be easy,” notes Evvie Munley of Leading Age.

Before moving to a final rule, CMS must think through how providers are to operationalize the agency’s broad and, sometimes idealized, goals.

Leading Age has recommended that CMS allow for a five-year phase in “to allow adequate opportunity for the significant new staff training and other changes nursing homes will have to make” to be in compliance with the new regulations, reports Munley.

One encouraging aspect of the CDC’s antibiotic stewardship program is a recognition that change will be incremental and will occur over time. In its summary of core elements for antibiotic stewardship in nursing homes, it calls on providers to “implement at least one policy or practice to improve antibiotic use,” and to “monitor at least one process of antibiotic use and at least one outcome from antibiotic use in your facility.”

“Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting,” the CDC concludes.

Fast Facts:

• 70% of nursing home residents receive one or more courses of antibiotics in a year.
• As many as 75% of antibiotics prescribed in nursing homes are unnecessary or inappropriate.
• Antimicrobial stewardship defined is a set of commitments and activities designed to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use.”

Source: Centers for Disease Control and Prevention.