Infection Control and QAPI

Infection control and prevention is fundamental to ensuring that a patient’s clinical condition improves without complications. There is very little official data to be found regarding home health infection numbers, probably because agencies are not required to submit annual infection statistics. There was a 2015 small sample study using OASIS responses M2310 and M2430 from 2010 which concluded about 3.5% of home health patients ended up hospitalized with an infection identified as one of the reasons for admission.

The Regulations

The 2017 Conditions of Participation (CoP) state in §484.70:

The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.
(a) Standard: Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases
(b) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include:
(1) A method for identifying infectious and communicable disease problems; and
(2) A plan for the appropriate actions that are expected to result in improvement and disease prevention.
(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s).

So what does this mean?

By now, your agency should be in the habit of educating staff about infection prevention and reporting and monitoring infections as they occur. If you have been doing this, you’re about halfway there. But, as you read above, the CoP has upped the ante on what is required of an infection control program. It is not enough to simply collect data in a binder to present in your annual report. You are required to take an active role in investigating the cause of infections for your agency, to provide education and other interventions to attempt to reduce the rate of infections, to monitor the effectiveness of your program, and to keep evidence of your progress.

Make sure you focus not only on identified risks, but also risks that are common to your geographic area. Check the CDC’s State-based Healthcare-Associated Infection Prevention Activities website for local information. State health departments publish statistics about infection trends, like TB rates, that you should periodically monitor. Keep an eye on the local news for information about flu, pneumonia, Legionnaire’s Disease and other infections. Most importantly, keep your staff updated on any trends that could impact your patient population.

Using reports for QAPI

The primary goal of a good infection control program is to reduce the rate of infections for your agency. Analyze your infection reports and look for patterns. Are higher numbers of infections occurring in certain facilities or communities? Is there a communication barrier that is making it difficult for your patients to understand the infection control education given to them? Are infections more likely to happen for certain staff members? Do certain diagnoses tend to drive higher infection rates?

This gives you a good starting point for your investigation. While you should definitely use trends in your data to direct your work, try to avoid jumping to conclusions and acting on them. Intervention through observation and education should be the first order of business with disciplinary action reserved for chronic non-compliance backed up by reasonable evidence and documentation. For example, you may assume a high rate of infections for a certain staff member is due to that staff member not following infection control protocols. You thoroughly review their paperwork, accompany them on several patient visits to observe their infection control practices, and interview patients on what they observe and what they have been taught about infection control. You may discover that the identified clinician exceeds standards but just happens to serve a higher percentage of patients with medical conditions that tend to develop more infections (like IV or wound care) or their patients live in a facility where residents interact often.

After Identification

Once you have identified some causes for the infection rate in your agency, take action to try to fix your problem areas. If your patients live in a facility that organizes social events, consider coordinating an infection control seminar to educate the residents. Arrange with building management to provide face masks and hand sanitizers to people who show symptoms of infection. Establish an infection control committee to help develop strategies for change.

Continue monitoring your infection reports to see if your interventions provide improvement in the observed area. If you can demonstrate that your infection numbers are decreasing after the new interventions were put in place, that is the best sign of a successful infection control program.

Make sure all staff are re-educated at least annually to reinforce your progress and keep regular communication with management in facilities where you service patients. During these annual meetings, take inventory of staff personal protective equipment (PPE). Ensure that items are in good working order and clinicians have all appropriate items for incidents that are most likely to occur in your geographic area. Over time people tend to become bogged down in routine, especially in home health where there are so many moving pieces to keep track of, so it’s a good idea to check in with reminders.

If you don’t see immediate improvement, don’t take it as a personal failure. QAPI is a continuous process that requires a lot of trial and error. Just make sure you document everything you do. If you provide staff inservices, make sure you keep a sign-in sheet and copy of the agenda. Document the date, time and content of infection control meetings and conversations. Keep copies of e-mail correspondence regarding new/improved/updated infection control processes.

A Note to Clinicians

Remember, understanding good infection control protocols helps you and your patients. Make sure you understand your agency’s infection control policies and procedures. Periodically examine your personal protective equipment (PPE) to ensure that they are in good condition and not expired. Make sure you have all appropriate PPE to serve the patients in your geographic area. Finally, report infections as soon as you know about them and be as detailed as possible in your documentation. This will help your whole team to reduce or prevent infections going forward.

More Information

If you would like more information about infection control, check out the Infection Control section of the CDC website and the Immunization & Infection Prevention BPIP section of the HHQI website. You can also check with your Medicare Administrative Contractor (MAC), your local health department, or your agency’s accrediting organization (if there is one). To submit questions about this article, connect with us on Facebook.