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F945
(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)
§483.95(e) Infection control.
A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program as described at §483.80(a)(2).
GUIDANCE §483.95(e)
All facilities must develop, implement and permanently maintain an effective training program for all staff, which includes, training on the standards, policies, and procedures for the infection prevention and control program as described at §483.80(a)(2), that is appropriate and effective, and as determined by staff need. For the purposes of this training requirement, staff includes all facility staff (direct and indirect care functions), contracted staff, and volunteers (training topics as appropriate to role).
Changes to the facility’s resident population, community infection risk, national standards, staff turnover, the facility’s physical environment, or facility assessment may necessitate ongoing revisions to the facility’s training program for infection prevention and control.
All training should support current scope and standards of practice through curricula which detail learning objectives, performance standards, evaluation criteria, and addresses potential risks to residents, staff, and volunteers if procedures are not followed. There should be a process in place to track staff participation in and understanding of the required training.
Such infection control training must, at a minimum, include the following areas (as described in §483.80(a)(2)):
• The facility’s surveillance system designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;
• When and to whom possible incidents of communicable disease or infections in the facility should be reported;
• How and when to use standard precautions, including proper hand hygiene practices and environmental cleaning and disinfection practices;
• How and when to use transmission-based precautions for a resident, including but not limited to, the type and its duration of use depending upon the infectious agent or organism involved;
• Occupational health policies, including the circumstances under which the facility must enforce work restrictions and when to self-report illness or exposures to potentially infectious materials (See 483.80(a)(2)(v)); and
• Proper infection prevention and control practices when performing resident care activities as it pertains to particular staff roles, responsibilities, and situations.
Please refer to F880 for a detailed description of these topics.
PROBES §483.95(e)
If there is a concern about infection prevention and control practices or healthcare-associated infections in the facility (F880), interview staff and review training records to determine the following:
• Did staff observations or did interviews with residents and/or resident representatives indicate a training need? Did staff report not receiving training about the concern identified by the surveyor?
• What process does the facility have to encourage staff to express concerns and request training in challenging situations? Does the facility respond to staff’s concerns and requests for training?
• Review the training coursework to determine if the content meets professional standards/guidelines and covers facility policy and procedures for infection prevention and control.
• Does the facility implement the training program and ensure staff are instructed to meet the requirements of §483.80(a)(2), Infection Control, F880?
• Verify that the facility has a mandatory requirement that all facility staff participate in infection prevention and control training, with a process in place to track such participation.
POTENTIAL ADDITIONAL TAGS FOR INVESTIGATION
For concerns related to infection prevention and control practices, see 42 CFR §483.80, Infection Control, tag F880.

 

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