MDS Alert

Look out: It’s easier than you think to get an F-441 deficiency citation

Did you know that F-441 — Infection Control was the most cited F-tag in each year from 2012 to 2015 and is the second-most cited F-tag so far for this year? With so much surveyor focus on infection control, you need to bolster your practices to stay out of the feds’ crosshairs.

Infection control also topped the list of focus areas for surveyors in the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group 2016/2017 Nursing Home Action Plan (see www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/2016-2017-Nursing-Home-Action-Plan.pdf). CMS has an Antibiotic Stewardship program and an Infection Control pilot both underway, so there’s no doubt that surveyors are cracking down on facilities that violate the F-441 mandates.

So what’s a nursing home to do? Thankfully, there are plenty of resources and action plans available; you just need to get everyone at your facility on board.

Why So Many F-441 Citations?

CMS cites many factors involved in the high incidence of healthcare associated infections (HAIs) in nursing homes, including (but not limited to):

• Understaffed facilities;
• Staff lacking the appropriate training or time to prevent infections early;
• Overtreatment with antibiotics;
• Increasing clinical complexity of the average nursing home resident;
• Frequent transitions between care settings that lead to HAI transmissions; and
• Lack of a systematic approach to prevent and identify HAIs.

Other common institutional factors include pathogen exposure in shared communal living spaces, such as on handrails and equipment, and even common air circulation, according to the State Operations Manual (SOM) Appendix PP.

And there are individual factors involved in the spread of HAIs in nursing homes, such as certain coexisting chronic diseases like diabetes, arthritis, cancer and anemia, as well as medications that affect resistance to infections like corticosteroids and chemotherapy. Residents may have impaired responses to infection or increased frequency of therapeutic toxicity, such as due to declining kidney and liver function.

What Surveyors are Looking For

In 2015, CMS updated the Infection Control Surveyor Worksheet — here’s a peek at what surveyors will look for in your facility when reviewing F-441 compliance:

• Are proper hand-washing techniques followed by the staff?
• Are gloves worn if there is contact with blood, specimens, tissue, body fluids, or excretions?
• Are gloves changed between resident contacts?
• Are staff who are providing direct care free from communicable diseases or infected skin lesions?
• Are precautions observed for the disposal of soiled linens, dressings, disposable equipment (sharps, etc.), and for the cleaning of contaminated reusable equipment?
• Are linens and laundry handled or transported in a manner to prevent the spread of infection?
• Are isolation precautions implemented when it is determined that a resident needs isolation?
• Are all other staff practices consistent with current infection control principles and do those practices prevent cross-contamination?
• Does the facility establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of disease and infection?
• Did the facility develop and implement policies and procedures related to influenza and pneumococcal immunizations?

Beware: If the surveyor answers “no” to any of these questions, you’ll get an F-441 citation.

Kick Your Infection Control Program into High Gear

Most of all, surveyors are looking for how well you’re implementing your facility’s Infection Control Program. Under F-441, your facility must establish an Infection Control Program under which you:

• Investigate, control, and prevent infections in your facility;
• Decide what procedures, such as isolation, you should apply to an individual resident; and
• Maintain a record of incidents and corrective actions related to infections.

Take action: According to the SOM, your Infection Control Program should contain the following five elements:

1. Conduct surveillance and investigations to prevent, as possible, the onset and spread of infection. Use two types of surveillance: process and outcome.

Process surveillance reviews practices related to resident care to identify whether staff actions are in compliance with practice standards for prevention and control policies and procedures, according to the National association of Directors of nursing administration in Long term Care (NADONA) toolkit for mastering F-441 Infection Control (www.nadona.org/wp-content/uploads/2016/04/F441-Infection-Control-Toolkit.pdf). Outcome surveillance identifies and reports evidence of infections, collecting data about individual cases of infection and comparing that data to standard written definitions of infections.

2. Use transmission-based precautions, when appropriate, in addition to standard precautions in an attempt to prevent and control outbreaks and cross-contamination.

“Standard precautions follow the principle that all blood, body fluids, secretions, non-intact skin, and mucous membranes may contain infectious agents that can be transmitted through either direct contact or contact with the contaminated environmental,” NADONA explains.

Transmission-based precautions, also known as “isolation precautions,” are actions that you would implement in addition to standard precautions based on the particular means of transmission. These include airborne, contact, and droplet precautions.

3. Record and analyze data about infection incidents and take corrective actions to improve infection control processes and outcomes. Your documentation should report the types of infections identified in your facility and any patterns or trends, according to NADONA.

Also document observations of staff compliance with infection prevention and control practices, as well as investigations into causes of individual residents’ infections.

4. Implement hand hygiene according to accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Hand washing seems like such a no-brainer, but the U.S. Centers for Disease Control and Prevention (CDC) estimates that proper hand hygiene could eliminate 80 percent of HAIs.

5. Properly store, handle, process, and transport linens to minimize contamination. Staff should consider all soiled linen as contaminated and use appropriate measures to prevent cross-contamination, NADONA says. Make sure staff are using leak-proof bags when linens are contaminated with blood or other bodily substances.

Resources: Check out the CDC’s Infection Control Assessment Tool for Long-Term Care Facilities at www.cdc.gov/hai/pdfs/IC/CDC_IC_Assessment_Tool_LTCF.pdf. To review the SOM Appendix PP containing the F-441 standards, go to www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. You can access the Infection Control Surveyor Worksheet at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS-20054-Infection-Control.pdf.