Is your facility at risk for one of the top vulnerabilities in SNF IPC programs? With the ongoing COVID-19 public health emergency, CMS has made Infection Prevention and Control programs (IPC) a significant focus of survey efforts. Surveys are bringing to light many shortcomings in facility IPC programs. In 2021, over 40% of nursing facilities across the nation received at least one infection control citation during a survey (CMS QCOR).

Many infections can be prevented and controlled through an active IPC program, the purpose of which is “to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” (CMS SOM Appendix PP).  Effective IPC programs, with their strong emphasis on prevention, will reduce the risk of pathogen transmission and development of healthcare-associated infections and improve residents’ quality of life. Some key areas to focus on include the following:

Vaccination Program

A major factor in infection prevention is the strength of the facility immunization program for residents and staff. Residents and staff should be offered the Influenza vaccine annually and the Pneumonia vaccine as recommended (try CDC’s PneumoRecs Vax Adviser app). Of course, the COVID vaccine, including any recommended booster doses, must also be offered.

Key areas to address include:

      • Compliance rate: Consider arranging for the pharmacist or a local infectious disease physician to provide education on the risks and benefits of vaccinations for your residents, their families and staff.
      • Evidence that residents and staff are being re-approached, on a routine basis, if they initially decline vaccines: Educate the residents and their families, as well as staff, on the risks and benefits of each and every vaccine. Document all education provided and each time you offer the vaccine.
      • Effectiveness of documentation of resident vaccinations in the clinical record.

Surveillance/Data Management

The next area of vulnerability to consider is whether the facility Infection Preventionist has readily accessible surveillance data on all current and past infection concerns.  Data should be divided by infection type. For example, line listings should be kept of infections in real time (e.g., UTI’s, COVID-19 or other respiratory concerns, GI issues, etc.)  Ensure that tracking tools are up to date and that documentation includes identification and analysis of any notable trends.

Antibiotic use, culture results and symptomatology data documentation should address tracking and trending in real time to catch any emerging threats or patterns. Evaluate surveillance data for trends related to factors such as, but not limited to resident location, infection type, and staff assignment.  It is the job of an efficient and observant IP to catch any emerging concerns before they become widespread, and to implement interventions to prevent the escalation of problems.

Screening and Testing Considerations

Consider procedures for screening and testing for staff and visitors. While CMS does not mandate testing for nursing home visitors, it is required that effective screening procedures are implemented. Procedures should include education on risks of COVID-19 and proper source control use EACH TIME a visitor enters the building. Also, when a visitor is demonstrating symptoms, a process must be in place to initiate specific action steps to safeguard against the possible spread of infection.

Staff must be routinely tested based on your county transmission levels.  . As such, clear responsibility must be outlined for tracking the community transmission levels and acting on changes, including assigning back up staff for monitoring this information. The best prevention for keeping your residents free from COVID-19 is a strong defense at the front door. Screening and testing should occur BEFORE staff report to the unit.  Visitors should be educated on hand hygiene and staff must monitor to ensure that proper hand hygiene is carried out. Ensure hand sanitizer is readily available throughout the building and that both visitors and residents are encouraged to use it.

Education and Adherence to Policies and Procedures

Well written policies and procedures are not effective if the staff are not aware of them and applying them in their daily workIf a surveyor questions a staff member regarding who is on precautions on their unit, do you feel confident that they know, and are knowledgeable about what PPE to wear for that particular resident? A knowledgeable IP is critical, but if the staff members caring for the residents are not familiar with resident needs, the facility will not be successful.  Consider these strategies:

      • The IP and other management team members should perform walking rounds to monitor for adherence to hand hygiene and other infection control standards.
      • Staff education should be followed by assessment of competency for donning and doffing PPE properly. Repetition is key to developing effective habits as part of the work flow.
      • As part of monitoring efforts, consider regular dialogue with staff on when they should be performing hand hygiene. Observe peri-care. Monitor meal trays being passed on the unit. Take the time to recognize positive performance and to address concerns in real time with a positive coaching approach. Education given in the moment is often better than random quizzes or classroom training for long term success.
      • Document each time you educate staff. Use facility audit tools and competencies and file them as proof that these have been done routinely.


Finally, ensure your facility is completing weekly NHSN reporting per guidelines and communicating outbreaks appropriately to staff, residents, family members, and public health authorities.  It is MANDATORY for SNF’s to report staff and resident testing results and vaccinations in the NHSN portal. Identify appropriate back-up personnel in case your primary person is unavailable.   Information on the NHSN reporting requirements can be found at COVID-19 Module | LTCF | NHSN | CDC. Review the information available and know the requirements for reporting.

Knowing  the top IPC program vulnerabilities, and regularly assessing your program in these hot button  areas, will help to move your facility forward in sustaining a successful and effective Infection Control and Prevention program.


Register to join Proactive February 15, 2022 for the webinar Developing An Infection Control and Prevention Program as part of The Proficient Infection Preventionist series



Blog By: Judy Caffrey, RN
Clinical Consultant

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