Infection Control Assessment Tool for Long-term Care Facilities

This tool is intended to assist in the assessment of infection control programs and practices in nursing homes and other long-term care facilities. If feasible, direct observations of infection control practices are encouraged. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit.

Overview

Section 1: Facility Demographics

Section 2: Infection Control Program and Infrastructure

Section 3: Direct Observation of Facility Practices (optional)

Section 4: Infection Control Guidelines and Other Resources

Infection Control Domains for Gap Assessment

Infection Control Program and Infrastructure

Healthcare Personnel and Resident Safety

Surveillance and Disease Reporting

Hand Hygiene

Personal Protective Equipment (PPE)

Respiratory/ Cough Etiquette

Antibiotic Stewardship

Injection safety and Point of Care Testing

Environmental Cleaning

Section 1. Facility Demographics V1-1

Facility Name (for health department use only)	Click here to enter text.
NHSN Facility Organization ID (for health department use only)	Click here to enter text.
State-assigned Unique ID	Click here to enter text.
Date of Assessment	Click here to enter a date.
Type of Assessment	☐ On-site ☐ Other (specify): Click here to enter text.
Rationale for Assessment (Select all that apply)	☐ Outbreak ☐ Input from accrediting organization or state survey agency ☐ NHSN data (if available) ☐ Collaborative (specify partner[s]): Click here to enter text.) ☐ Other (specify): Click here to enter text.
Is the facility licensed by the state?	☐ Yes ☐ No
Is the facility certified by the Centers for Medicare & Medicaid Services (CMS)	☐ Yes ☐ No
Facility type	☐ Nursing home ☐ Intermediate care facility ☐ Assisted living facility ☐ Other (specify): Click here to enter text.
Number of licensed beds	Click here to enter text.
Total staff hours per week dedicated to infection prevention and control activities	Click here to enter text.
Is the facility affiliated with a hospital?	☐ Yes (specify – for health department use only): Click here to enter text. ☐ No

Section 2: Infection Control Program and Infrastructure

Infection Control Program and Infrastructure
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility has specified a person (e.g., staff, consultant) who is responsible for coordinating the IC program.	Yes No
The person responsible for coordinating the infection prevention program has received training in IC Examples of training may include: Successful completion of initial and/or recertification exams developed by the Certification Board for Infection Control & Epidemiology; Participation in infection control courses organized by the state or recognized professional societies (e.g., APIC, SHEA).	Yes No
The facility has a process for reviewing infection surveillance data and infection prevention activities (e.g., presentation at QA committee).	Yes No
Written infection control policies and procedures are available and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-441), or standards. Note: Policies and procedures should be tailored to the facility and extend beyond OSHA bloodborne pathogen training or the CMS State Operations Manual	Yes No
Written infection control policies and procedures are reviewed at least annually or according to state or federal requirements, and updated if appropriate.	Yes No
The facility has a written plan for emergency preparedness (e.g., pandemic influenza or natural disaster).	Yes No

Healthcare Personnel and Resident Safety
Elements to be assessed	Assessment	Notes/Areas for Improvement
Healthcare Personnel
The facility has work-exclusion policies concerning avoiding contact with residents when personnel have potentially transmissible conditions which do not penalize with loss of wages, benefits, or job status.	Yes No
The facility educates personnel on prompt reporting of signs/symptoms of a potentially transmissible illness to a supervisor	Yes No
The facility conducts baseline Tuberculosis (TB) screening for all new personnel	Yes No
The facility has a policy to assess healthcare personnel risk for TB (based on regional, community data) and requires periodic (at least annual) TB screening if indicated.	Yes No
The facility offers Hepatitis B vaccination to all personnel who may be exposed to blood or body fluids as part of their job duties	Yes No
The facility offers all personnel influenza vaccination annually.	Yes No
The facility maintains written records of personnel influenza vaccination from the most recent influenza season.	Yes No
The facility has an exposure control plan which addresses potential hazards posed by specific services provided by the facility (e.g., blood-borne pathogens). Note: A model template, which includes a guide for creating an exposure control plan that meets the requirements of the OSHA Bloodborne Pathogens Standard is available at: https://www.osha.gov/Publications/osha3186.pdf	Yes No
All personnel receive training and competency validation on managing a blood-borne pathogen exposure at the time of employment. Note: An exposure incident refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an individual’s duties.	Yes No
All personnel received training and competency validation on managing a potential blood-borne pathogen exposure within the past 12 months.	Yes No
Resident Safety
The facility currently has a written policy for to assess risk for TB (based on regional, community data) and provide screening to residents on admission.	Yes No
The facility documents resident immunization status for pneumococcal vaccination at time of admission.	Yes No
The facility offers annual influenza vaccination to residents.	Yes No

Surveillance and Disease Reporting
Elements to be assessed	Assessment	Notes/Areas for Improvement
Surveillance
The facility has written intake procedures to identify potentially infectious persons at the time of admission. Examples: Documenting recent antibiotic use, and history of infections or colonization with C.difficile or antibiotic-resistant organisms	Yes No
The facility has system for notification of infection prevention coordinator when antibiotic-resistant organisms or C.difficile are reported by clinical laboratory.	Yes No
The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility.	Yes No
The facility has system to follow-up on clinical information, (e.g., laboratory, procedure results and diagnoses), when residents are transferred to acute care hospitals for management of suspected infections, including sepsis. Note: Receiving discharge records at the time of re-admission is not sufficient to answer “yes”	Yes No
Disease Reporting
The facility has a written plan for outbreak response which includes a definition, procedures for surveillance and containment, and a list of syndromes or pathogens for which monitoring is performed.	Yes No
The facility has a current list of diseases reportable to public health authorities.	Yes No
The facility can provide point(s) of contact at the local or state health department for assistance with outbreak response.	Yes No

Hand Hygiene
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility hand hygiene (HH) policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a resident with known or suspected C. difficile or norovirus.	Yes No
All personnel receive training and competency validation on HH at the time of employment.	Yes No
All personnel received training and competency validation on HH within the past 12 months.	Yes No
The facility audits (monitors and documents) adherence to HH Note: If yes, facility should provide documentation of audits	Yes No
The facility provides feedback to personnel regarding their HH performance. Note: If yes, facility should provide documentation of feedback reports	Yes No
Supplies necessary for adherence to HH (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in resident care areas (i.e., nursing units, resident rooms, therapy rooms).	Yes No

Personal Protective Equipment (PPE)
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility has a policy on Standard Precautions which includes selection and use of PPE (e.g., indications, donning/doffing procedures).	Yes No
The facility has a policy on Transmission-based Precautions that includes the clinical conditions for which specific PPE should be used (e.g., C.diff, Influenza).	Yes No
Appropriate personnel receive job-specific training and competency validation on proper use of PPE at the time of employment.	Yes No
Appropriate personnel received job-specific training and competency validation on proper use of PPE within the past 12 months.	Yes No
The facility audits (monitors and documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing). Note: If yes, facility should provide documentation of audits	Yes No
The facility provides feedback to personnel regarding their PPE use. Note: If yes, facility should provide documentation of feedback reports	Yes No
Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (i.e., nursing units, therapy rooms).	Yes No

Respiratory Hygiene/Cough Etiquette
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility has signs posted at entrances with instructions to individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?	Yes No
The facility provides resources for performing hand hygiene near the entrance and in common areas.	Yes No
The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility.	Yes No
The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?	Yes No
All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens	Yes No

Antibiotic Stewardship
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility can demonstrate leadership support for efforts to improve antibiotic use (antibiotic stewardship).	Yes No
The facility has identified individuals accountable for leading antibiotic stewardship activities	Yes No
The facility has access to individuals with antibiotic prescribing expertise (e.g. ID trained physician or pharmacist).	Yes No
The facility has written policies on antibiotic prescribing.	Yes No
The facility has implemented practices in place to improve antibiotic use.	Yes No
The facility has a report summarizing antibiotic use from pharmacy data created within last 6 months. Note: Report could include number of new starts, types of drugs prescribed, number of days of antibiotic treatment) from the pharmacy on a regular basis	Yes No
The facility has a report summarizing antibiotic resistance (i.e., antibiogram) from the laboratory created within the past 24 months.	Yes No
The facility provides clinical prescribers with feedback about their antibiotic prescribing practices. Note: If yes, facility should provide documentation of feedback reports	Yes No
The facility has provided training on antibiotic use (stewardship) to all nursing staff within the last 12 months.	Yes No
The facility has provided training on antibiotic use (stewardship) to all clinical providers with prescribing privileges within the last 12 months.	Yes No

Injection Safety and Point of Care Testing
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility has a policy on injection safety which includes protocols for performing finger sticks and point of care testing (e.g., assisted blood glucose monitoring, or AMBG).	Yes No
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures at time of employment. Note: If point of care tests are performed by contract personnel, facility should verify that training is provided by contracting company	Yes No
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures within the past 12 months. Note: If point of care tests are performed by contract personnel, facility should verify that training is provided by contracting company	Yes No
The facility audits (monitors and documents) adherence to injection safety procedures during point of care testing (e.g., AMBG). Note: If yes, facility should provide documentation of audits	Yes No
The facility provides feedback to personnel regarding their adherence to injection safety procedures during point of care testing (e.g., AMBG). Note: If yes, facility should provide documentation of feedback reports	Yes No
Supplies necessary for adherence to safe injection practices (e.g., single-use, auto-disabling lancets, sharps containers) are readily accessible in resident care areas (i.e., nursing units).	Yes No
The facility has policies and procedures to track personnel access to controlled substances to prevent narcotics theft/drug diversion.	Yes No

Environmental Cleaning
Elements to be assessed	Assessment	Notes/Areas for Improvement
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms.	Yes No
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. diff).	Yes No
The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas.	Yes No
The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.).	Yes No
Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, dental equipment) are cleaned and reprocessed appropriately prior to use on another patient. Note: If external consultants (e.g., wound care nurses, dentists or podiatrists) provide services in the facility, the facility must verify these providers have adequate supplies and space to follow appropriate cleaning/disinfection (reprocessing) procedures to prevent transmission of infectious agents Note: Select not applicable for the following: All medical devices are single use only or dedicated to individual residents No procedures involving medical devices are performed in the facility by staff or external consultants External consultants providing services which involve medical devices have adequate supplies that no devices are shared on-site and all reprocessing is performed off-site	Yes No Not Applicable
Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment. Note: If environmental services are performed by contract personnel, facility should verify that training is provided by contracting company	Yes No
Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months. Note: If environmental services are performed by contract personnel, facility should verify that training is provided by contracting company	Yes No
The facility audits (monitors and documents) quality of cleaning and disinfection procedures. Note: If yes, facility should provide documentation of audits	Yes No
The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures. Note: If yes, facility should provide documentation of feedback reports	Yes No
Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered, including products labeled as effective against C.difficile and Norovirus) are available. Note: If environmental services are performed by contract personnel, facility should verify that appropriate EPA-registered products are provided by contracting company	Yes No

Section 3: Direct Observation of Facility Practices (optional)

Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container that is used for subsequent patients; reuse of lancets) can result in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected patients.

Point of Care Testing Observations (e.g., assisted blood glucose monitoring)
HH performed	New gloves worn	*Single use, lancet used?	**Testing meter	Gloves removed	HH performed
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Yes No	Yes No	Yes No	Dedicated to resident, cleaned/disinfected before storing Cleaned/disinfected before next resident	Yes No	Yes No
Notes: *Lancet holder devices (e.g., lancing penlets) are not suitable for multi-patient use. **If the manufacturer does not provide instructions for cleaning and disinfection, then the testing meter should not be used for >1 patient.

Hand Hygiene and Contact Precautions observation tool
Staff type*	Type of opportunity	HH performed?	Gown or glove indicated?	Gown/glove used?
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
Click here to enter text.	Room entry Room exit Before resident contact After resident contact Before glove After glove Other: Click here to enter text.	Alcohol-rub Hand Wash No HH done	Gown only Glove only Both No	Gown used Glove used Both Neither
*Staff key: MD= Physician, PA= Physician assist., NP= Advanced practice nurse, RN=Registered nurse, LPN=Licensed practice nurse, CNA=Certified nurse aide or assist., REHAB= Rehabilitation staff (e.g. physical, occupational, speech), DIET=Dietary staff, EVS=Environmental services or housekeeping staff, SW = Social worker, UNK = Unknown/unable to determine

Section 4: Infection Control Guidelines and Other Resources

General Infection Prevention

☐ CDC Infection Prevention Resources for Long-term Care: http://www.cdc.gov/longtermcare

☐ CDC/HICPAC Guidelines and recommendations: http://www.cdc.gov/HAI/prevent/prevent_pubs.html

☐ CMS State Operations Manual, Appendix PP, Released Nov 2014 (IC Guidance on pages 182-220): https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R127SOMA.PDF

Healthcare Personnel Safety

☐ Guideline for Infection Control in Healthcare Personnel: http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

☐ Immunization of HealthCare Personnel: http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html

☐ Occupational Safety & Health Administration (OSHA) Bloodborne Pathogen and Needlestick Prevention Standard: https://www.osha.gov/SLTC/bloodbornepathogens/index.html

Hand Hygiene

☐ Guideline for Hand Hygiene in Healthcare Settings: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

☐ Hand Hygiene in Healthcare Settings: http://www.cdc.gov/handhygiene

Examples of Hand Hygiene Auditing Tools:

☐ Measuring Hand Hygiene Adherence: Overcoming the Challenges: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf

☐ iScrub: http://compepi.cs.uiowa.edu/index.php/Research/IScrub

Personal Protective Equipment

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation2007.pdf

☐ Management of Multi-Drug Resistant Organisms in Healthcare Settings, 2006: http://www.cdc.gov/hicpac/pdf/guidelines/MDROGuideline2006.pdf

☐ Guidance for the Selection and Use of Personal Protective Equipment in Healthcare Settings: http://www.cdc.gov/HAI/prevent/ppe.html

Respiratory Hygiene/Cough Etiquette

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation2007.pdf

☐ Respiratory Hygiene and Cough Etiquette in Healthcare Settings: http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

☐ Recommendations for preventing the spread of influenza: http://www.cdc.gov/flu/professionals/infectioncontrol/

☐ CDC Influenza Vaccination Tool-kit for Long-term Care Employers: http://www.cdc.gov/flu/toolkit/long-term-care/index.htm

Antimicrobial stewardship

☐ CDC Implementation Resources for Antibiotic Stewardship: http://www.cdc.gov/getsmart/healthcare/implementation.html

Safe Injection and Point of Care Testing Practices

☐ 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

☐ CDC Injection Safety Web Materials: http://www.cdc.gov/injectionsafety

☐ CDC training video and related Safe Injection Practices Campaign materials: http://oneandonlycampaign.org

☐ Infection Prevention during Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html

☐ Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration: http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html

Environmental Infection Control

☐ Guidelines for Environmental Infection Control in Healthcare Facilities: http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

☐ EPA Listing of disinfectant products with sporicidal activity against C. difficile: http://www.epa.gov/oppad001/list_k_clostridium.pdf

☐ Options for Evaluating Environmental Infection Control: http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html

Resources to assist with evaluation and response to breaches in infection control

☐ Patel PR, Srinivasan A, Perz JF. Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control. 2008 Dec;36(10);685-90

☐ Steps for Evaluating an Infection Control Breach: http://www.cdc.gov/hai/outbreaks/steps_for_eval_IC_breach.html

☐ Patient Notification Toolkit: http://www.cdc.gov/injectionsafety/pntoolkit/index.html

Assessment Summary

I. Infection Control Program and Infrastructure
Incomplete Elements
The facility has specified a person (e.g., staff, consultant) who is responsible for coordinating the IC program.
The person responsible for coordinating the infection prevention program has received training in IC
The facility has a process for reviewing infection surveillance data and infection prevention activities (e.g., presentation at QA committee).
Written infection control policies and procedures are available and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-441), or standards.
Written infection control policies and procedures are reviewed at least annually or according to state or federal requirements, and updated if appropriate.
The facility has a written plan for emergency preparedness (e.g., pandemic influenza or natural disaster).
Summary of ‘No’ Responses
The facility has specified a person (e.g., staff, consultant) who is responsible for coordinating the IC program.
The person responsible for coordinating the infection prevention program has received training in IC
The facility has a process for reviewing infection surveillance data and infection prevention activities (e.g., presentation at QA committee).
Written infection control policies and procedures are available and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-441), or standards.
Written infection control policies and procedures are reviewed at least annually or according to state or federal requirements, and updated if appropriate.
The facility has a written plan for emergency preparedness (e.g., pandemic influenza or natural disaster).
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

II. Healthcare Personnel and Resident Safety
Incomplete Elements
Healthcare Personnel
The facility has work-exclusion policies concerning avoiding contact with residents when personnel have potentially transmissible conditions which do not penalize with loss of wages, benefits, or job status.
The facility educates personnel on prompt reporting of signs/symptoms of a potentially transmissible illness to a supervisor
The facility conducts baseline Tuberculosis (TB) screening for all new personnel
The facility has a policy to assess healthcare personnel risk for TB (based on regional, community data) and requires periodic (at least annual) TB screening if indicated.
The facility offers Hepatitis B vaccination to all personnel who may be exposed to blood or body fluids as part of their job duties
The facility offers all personnel influenza vaccination annually.
The facility maintains written records of personnel influenza vaccination from the most recent influenza season.
The facility has an exposure control plan which addresses potential hazards posed by specific services provided by the facility (e.g., blood-borne pathogens).
All personnel receive training and competency validation on managing a blood-borne pathogen exposure at the time of employment.
All personnel received training and competency validation on managing a potential blood-borne pathogen exposure within the past 12 months.
Resident Safety
The facility currently has a written policy for to assess risk for TB (based on regional, community data) and provide screening to residents on admission.
The facility documents resident immunization status for pneumococcal vaccination at time of admission.
The facility offers annual influenza vaccination to residents.
Summary of ‘No’ Responses
Healthcare Personnel
The facility has work-exclusion policies concerning avoiding contact with residents when personnel have potentially transmissible conditions which do not penalize with loss of wages, benefits, or job status.
The facility educates personnel on prompt reporting of signs/symptoms of a potentially transmissible illness to a supervisor
The facility conducts baseline Tuberculosis (TB) screening for all new personnel
The facility has a policy to assess healthcare personnel risk for TB (based on regional, community data) and requires periodic (at least annual) TB screening if indicated.
The facility offers Hepatitis B vaccination to all personnel who may be exposed to blood or body fluids as part of their job duties
The facility offers all personnel influenza vaccination annually.
The facility maintains written records of personnel influenza vaccination from the most recent influenza season.
The facility has an exposure control plan which addresses potential hazards posed by specific services provided by the facility (e.g., blood-borne pathogens).
All personnel receive training and competency validation on managing a blood-borne pathogen exposure at the time of employment.
All personnel received training and competency validation on managing a potential blood-borne pathogen exposure within the past 12 months.
Resident Safety
The facility currently has a written policy for to assess risk for TB (based on regional, community data) and provide screening to residents on admission.
The facility documents resident immunization status for pneumococcal vaccination at time of admission.
The facility offers annual influenza vaccination to residents.
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

III. Surveillance and Disease Reporting
Incomplete Elements
Surveillance
The facility has written intake procedures to identify potentially infectious persons at the time of admission.
The facility has system for notification of infection prevention coordinator when antibiotic-resistant organisms or C.difficile are reported by clinical laboratory.
The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility.
The facility has system to follow-up on clinical information, (e.g., laboratory, procedure results and diagnoses), when residents are transferred to acute care hospitals for management of suspected infections, including sepsis.
Disease Reporting
The facility has a written plan for outbreak response which includes a definition, procedures for surveillance and containment, and a list of syndromes or pathogens for which monitoring is performed.
The facility has a current list of diseases reportable to public health authorities.
The facility can provide point(s) of contact at the local or state health department for assistance with outbreak response.
Summary of ‘No’ Responses
Surveillance
The facility has written intake procedures to identify potentially infectious persons at the time of admission.
The facility has system for notification of infection prevention coordinator when antibiotic-resistant organisms or C.difficile are reported by clinical laboratory.
The facility has a written surveillance plan outlining the activities for monitoring/tracking infections occurring in residents of the facility.
The facility has system to follow-up on clinical information, (e.g., laboratory, procedure results and diagnoses), when residents are transferred to acute care hospitals for management of suspected infections, including sepsis.
Disease Reporting
The facility has a written plan for outbreak response which includes a definition, procedures for surveillance and containment, and a list of syndromes or pathogens for which monitoring is performed.
The facility has a current list of diseases reportable to public health authorities.
The facility can provide point(s) of contact at the local or state health department for assistance with outbreak response.
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

IV. Hand Hygiene
Incomplete Elements
The facility hand hygiene (HH) policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a resident with known or suspected C. difficile or norovirus.
All personnel receive training and competency validation on HH at the time of employment.
All personnel received training and competency validation on HH within the past 12 months.
The facility audits (monitors and documents) adherence to HH
The facility provides feedback to personnel regarding their HH performance.
Supplies necessary for adherence to HH (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in resident care areas (i.e., nursing units, resident rooms, therapy rooms).
Summary of ‘No’ Responses
The facility hand hygiene (HH) policies promote preferential use of alcohol-based hand rub over soap and water except when hands are visibly soiled (e.g., blood, body fluids) or after caring for a resident with known or suspected C. difficile or norovirus.
All personnel receive training and competency validation on HH at the time of employment.
All personnel received training and competency validation on HH within the past 12 months.
The facility audits (monitors and documents) adherence to HH
The facility provides feedback to personnel regarding their HH performance.
Supplies necessary for adherence to HH (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible in resident care areas (i.e., nursing units, resident rooms, therapy rooms).
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

V. Personal Protective Equipment (PPE)
Incomplete Elements
The facility has a policy on Standard Precautions which includes selection and use of PPE (e.g., indications, donning/doffing procedures).
The facility has a policy on Transmission-based Precautions that includes the clinical conditions for which specific PPE should be used (e.g., C.diff, Influenza).
Appropriate personnel receive job-specific training and competency validation on proper use of PPE at the time of employment.
Appropriate personnel received job-specific training and competency validation on proper use of PPE within the past 12 months.
The facility audits (monitors and documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing).
The facility provides feedback to personnel regarding their PPE use.
Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (i.e., nursing units, therapy rooms).
Summary of ‘No’ Responses
The facility has a policy on Standard Precautions which includes selection and use of PPE (e.g., indications, donning/doffing procedures).
The facility has a policy on Transmission-based Precautions that includes the clinical conditions for which specific PPE should be used (e.g., C.diff, Influenza).
Appropriate personnel receive job-specific training and competency validation on proper use of PPE at the time of employment.
Appropriate personnel received job-specific training and competency validation on proper use of PPE within the past 12 months.
The facility audits (monitors and documents) adherence to PPE use (e.g., adherence when indicated, donning/doffing).
The facility provides feedback to personnel regarding their PPE use.
Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns, masks) are readily accessible in resident care areas (i.e., nursing units, therapy rooms).
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

VI. Respiratory/ Cough Etiquette
Incomplete Elements
The facility has signs posted at entrances with instructions to individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?
The facility provides resources for performing hand hygiene near the entrance and in common areas.
The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility.
The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?
All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens
Summary of ‘No’ Responses
The facility has signs posted at entrances with instructions to individuals with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?
The facility provides resources for performing hand hygiene near the entrance and in common areas.
The facility offers facemasks to coughing residents and other symptomatic persons upon entry to the facility.
The facility educates family and visitors to notify staff and take appropriate precautions if they are having symptoms of respiratory infection during their visit?
All personnel receive education on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

VII. Antibiotic Stewardship
Incomplete Elements
The facility can demonstrate leadership support for efforts to improve antibiotic use (antibiotic stewardship).
The facility has identified individuals accountable for leading antibiotic stewardship activities
The facility has access to individuals with antibiotic prescribing expertise (e.g. ID trained physician or pharmacist).
The facility has written policies on antibiotic prescribing.
The facility has implemented practices in place to improve antibiotic use.
The facility has a report summarizing antibiotic use from pharmacy data created within last 6 months.
The facility has a report summarizing antibiotic resistance (i.e., antibiogram) from the laboratory created within the past 24 months.
The facility provides clinical prescribers with feedback about their antibiotic prescribing practices.
The facility has provided training on antibiotic use (stewardship) to all nursing staff within the last 12 months.
The facility has provided training on antibiotic use (stewardship) to all clinical providers with prescribing privileges within the last 12 months.
Summary of ‘No’ Responses
The facility can demonstrate leadership support for efforts to improve antibiotic use (antibiotic stewardship).
The facility has identified individuals accountable for leading antibiotic stewardship activities
The facility has access to individuals with antibiotic prescribing expertise (e.g. ID trained physician or pharmacist).
The facility has written policies on antibiotic prescribing.
The facility has implemented practices in place to improve antibiotic use.
The facility has a report summarizing antibiotic use from pharmacy data created within last 6 months.
The facility has a report summarizing antibiotic resistance (i.e., antibiogram) from the laboratory created within the past 24 months.
The facility provides clinical prescribers with feedback about their antibiotic prescribing practices.
The facility has provided training on antibiotic use (stewardship) to all nursing staff within the last 12 months.
The facility has provided training on antibiotic use (stewardship) to all clinical providers with prescribing privileges within the last 12 months.
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

VIII. Injection safety and Point of Care Testing
Incomplete Elements
The facility has a policy on injection safety which includes protocols for performing finger sticks and point of care testing (e.g., assisted blood glucose monitoring, or AMBG).
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures at time of employment.
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures within the past 12 months.
The facility audits (monitors and documents) adherence to injection safety procedures during point of care testing (e.g., AMBG).
The facility provides feedback to personnel regarding their adherence to injection safety procedures during point of care testing (e.g., AMBG).
Supplies necessary for adherence to safe injection practices (e.g., single-use, auto-disabling lancets, sharps containers) are readily accessible in resident care areas (i.e., nursing units).
The facility has policies and procedures to track personnel access to controlled substances to prevent narcotics theft/drug diversion.
Summary of ‘No’ Responses
The facility has a policy on injection safety which includes protocols for performing finger sticks and point of care testing (e.g., assisted blood glucose monitoring, or AMBG).
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures at time of employment.
Personnel who perform point of care testing (e.g., AMBG) receive training and competency validation on injection safety procedures within the past 12 months.
The facility audits (monitors and documents) adherence to injection safety procedures during point of care testing (e.g., AMBG).
The facility provides feedback to personnel regarding their adherence to injection safety procedures during point of care testing (e.g., AMBG).
Supplies necessary for adherence to safe injection practices (e.g., single-use, auto-disabling lancets, sharps containers) are readily accessible in resident care areas (i.e., nursing units).
The facility has policies and procedures to track personnel access to controlled substances to prevent narcotics theft/drug diversion.
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

IX. Environmental Cleaning
Incomplete Elements
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms.
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. diff).
The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas.
The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.).
Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, dental equipment) are cleaned and reprocessed appropriately prior to use on another patient.
Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment.
Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months.
The facility audits (monitors and documents) quality of cleaning and disinfection procedures.
The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures.
Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered, including products labeled as effective against C.difficile and Norovirus) are available.
Summary of ‘No’ Responses
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of resident rooms.
The facility has written cleaning/disinfection policies which include routine and terminal cleaning and disinfection of rooms of residents on contact precautions (e.g., C. diff).
The facility has written cleaning/disinfection policies which include cleaning and disinfection of high-touch surfaces in common areas.
The facility cleaning/disinfection policies include handling of equipment shared among residents (e.g., blood pressure cuffs, rehab therapy equipment, etc.).
Facility has policies and procedures to ensure that reusable medical devices (e.g., blood glucose meters, wound care equipment, podiatry equipment, dental equipment) are cleaned and reprocessed appropriately prior to use on another patient.
Appropriate personnel receive job-specific training and competency validation on cleaning and disinfection procedures at the time of employment.
Appropriate personnel received job-specific training and competency validation on cleaning and disinfection procedures within the past 12 months.
The facility audits (monitors and documents) quality of cleaning and disinfection procedures.
The facility provides feedback to personnel regarding the quality of cleaning and disinfection procedures.
Supplies necessary for appropriate cleaning and disinfection procedures (e.g., EPA-registered, including products labeled as effective against C.difficile and Norovirus) are available.
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations:

Follow Up Activities:	☐ Repeat on-site assessment planned (date: Click here to enter a date.)
☐ Repeat remote (phone/email) assessment planned (date: Click here to enter a date.)
☐ Other (specify): Click here to enter text.

☐ IC Program and Infrastructure ☐ HCP Safety

☐ Surveillance/Reporting ☐ Hand Hygiene ☐ PPE

☐ Respiratory Etiquette ☐Antibiotic Stewardship

☐ Injection Safety/POC Testing ☐ Environmental Cleaning