INFECTION PREVENTION AND CONTROL SERVICES
8:36-18.1 Infection control program
- The facility shall develop and implement an infection prevention and control program.
- The licensed professional nurse, in coordination with the administrator, shall be responsible for the direction, provision, and quality of infection prevention and control services. The health care services director, in coordination with the administrator, shall be responsible for, but not limited to, developing and maintaining written objectives, a policy and procedure manual, and an organizational plan for the infection prevention and control
8:36-18.2 Development of infection control policies and procedures
- The facility shall develop, implement, and review, at least annually, written policies and procedures regarding infection prevention and control. Written policies and procedures shall be consistent with the following Centers for Disease Control publications and OSHA standards, incorporated herein by reference, as amended and supplemented:
- Guidelines for Hand Hygiene in Health Care Settings, MMWR/51 (RR- 16), October 25, 2002;
- Prevention and Control of Tuberculosis in Facilities Providing Long- Term Care to the Elderly, Recommendations of the Advisory Committee for Elimination of Tuberculosis, MMWR/39 (RR-10), July 13, 1990;
- Guidelines for Preventing Health Care-Associated Pneumonia, MMWR/53 (RR-03), March 26, 2004;
- Bloodborne Pathogens, Occupational Safety and Health Standards, 29 CFR 1910.1030, as amended and supplemented; and
- Fact Sheet on Respiratory Hygiene/Cough Etiquette in Healthcare Settings, December 17, 2003, Department of Health and Human Services, Centers for Disease Control and
- Centers for Disease Control publications can be obtained from: National Technical Information Service
U.S. Department of Commerce 5285 Port Royal Road Springfield, VA 22161
Superintendent of Documents
U.S. Government Printing Office Washington, D.C. 20402
- The facility shall document evidence of annual vaccination against influenza for each resident, in accordance with the General Recommendations on Immunization of the Advisory Committee on Immunization Practices of the Centers for Disease Control, February 8, 2002, incorporated herein by reference, as amended and supplemented, unless such vaccination is medically contraindicated or the resident has refused the vaccine, in accordance with
N.J.A.C. 8:36-4.1(a). The General Recommendations on Immunization of the Advisory Committee on Immunization Practices of the Centers for Disease Control, February 8, 2002, which are available on the Internet at http://www.cdc.gov/nip/publications/acip-list.htm. Influenza vaccination for all residents accepting the vaccine shall be completed by November 30 of each year. Residents admitted after this date, during the flu season and up to February 1, shall, as medically appropriate, receive influenza vaccination prior to or on admission unless refused by the resident.
- The facility shall document evidence of vaccination against pneumococcal disease for all residents who are 65 years of age or older, in accordance with the General Recommendations on Immunization of the Advisory Committee on Immunization Practices of the Centers for Disease Control, February 8, 2002, incorporated herein by reference, as amended and supplemented, unless such vaccination is medically contraindicated or the resident has refused offer of the vaccine in accordance with N.J.A.C. 8:36-4.1(a). The General Recommendations on Immunization of the Advisory Committee on Immunization Practices of the Centers for Disease Control, February 8, 2002, which are available on the Internet at http://wwwcdc.gov/nip/publications/acip-htm. The facility shall provide or arrange for pneumococcal vaccination of residents who have not received this immunization, prior to or on admission unless the resident refuses offer of the vaccine.
8:36-18.3 General infection control policies and procedures
(a) Written policies and procedures shall be established and implemented regarding infection prevention and control, including, but not limited to, policies and procedures for the following:
- In accordance with Chapter II, New Jersey State Sanitary Code, Communicable Diseases, at N.J.A.C. 8:57, a system for investigating, reporting, and evaluating the occurrence of all infections or diseases which are reportable or conditions which may be related to activities and procedures of the facility, and maintaining records for all residents or personnel having these infections, diseases, or conditions;
- Infection control in accordance with OSHA Standards 29 CFR 1910.1030, Bloodborne pathogens, incorporated herein by reference, as amended and supplemented;
- Exclusion from work, and authorization to return to work, for personnel with communicable diseases;
- Surveillance techniques to minimize sources and transmission of infection;
- Techniques to be used during each resident contact, including handwashing before and after caring for a resident;
- Protocols for identification of residents with communicable diseases and education of residents regarding prevention and spread of communicable diseases;
- Sterilization, disinfection, and cleaning practices and techniques used in the facility, including, but not limited to, the following:
- Care of utensils, instruments, solutions, dressings, articles, and surfaces;
- Selection, storage, use, and disposition of disposable and nondisposable resident care Disposable items shall not be reused;
- Methods to ensure that sterilized materials are packaged, labeled, processed, transported, and stored to maintain sterility and to permit identification of expiration dates; and
- Care of urinary catheters, intravenous catheters, respiratory therapy equipment, and other devices and equipment that provide a portal of entry for pathogenic microorganisms; and
- Needles and syringes used by residents as part of home self-care shall be disposed of in accordance with N.J.S.A. 2C:l36-6.1 and N.J.A.C. 8:43E-7, and amendments thereto.
8:36-18.4 Employee health and resident policies and procedures for infection prevention and control
- Each new employee upon employment shall receive a two-step Mantoux tuberculin skin test with five tuberculin units of purified protein derivative. The only exceptions shall be employees with documented negative two-step Mantoux skin test results (zero to nine millimeters of induration) within the last year, employees with a documented positive Mantoux skin test result (10 or more millimeters of induration), employees who have received appropriate medical treatment for tuberculosis, or when medically contraindicated. Results of the Mantoux tuberculin skin tests administered to new employees shall be acted upon as follows:
- If the first step of the Mantoux tuberculin skin test result is less than 10 millimeters of induration, the second step of the two-step Mantoux test shall be administered one to three weeks
- If the Mantoux test is significant (10 millimeters or more of induration), a chest x-ray shall be performed and, if necessary, followed by chemoprophylaxis or
- Any employee with positive results shall be referred to the employee’s personal physician and shall be excluded from work until the physician provides written approval to
- The facility shall have written policies and procedures establishing timeframes, requiring annual Mantoux tuberculin skin tests for all employees except those exempted under (a)
- Employees who have signs or symptoms of a communicable disease shall not be permitted to perform functions that expose residents to risk of transmission of the
- If a communicable disease prevents the employee from working for a period of more than three days, a physician’s statement approving the employee’s return shall be required prior to the employee’s return to
- The facility shall develop and implement procedures for the care of employees who become ill while at work or who have a work-related
- The facility shall maintain listings of all residents and personnel who have reportable infections, diseases, or
- High-level disinfection techniques approved by the Department shall be used for all reusable respiratory therapy equipment and instruments that touch mucous
- Disinfection procedures for items that come in contact with bedpans, sinks, and toilets shall conform to facility established protocols for cleaning and disinfection.
- All residents shall be provided with an opportunity to wash their hands before each meal and shall be encouraged to do so. Staff shall wash their hands before each meal and before assisting residents in
- Personnel who have had contact with resident excretions, secretions, or blood, whether directly or indirectly, in activities such as performing a physical examination, providing catheter care, and emptying bedpans, shall wash their hands with soap and warm water for between 10 and 30 seconds or use other effective hand sanitation techniques immediately after such
- Equipment and supplies used for sterilization, disinfection, and decontamination purposes shall be maintained according to manufacturers’ specifications.
- The facility shall maintain records documenting contagious diseases contracted by employees during employment, as specified at N.J.A.C. 8:57- 1.3(a) and (b).
8:36-18.5 Staff education and training for infection prevention and control
All staff members shall be informed about the facility’s infection control procedures, including personal hygiene requirements.
8:36-18.6 Regulated medical waste
- The facility shall develop policies and procedures for the collection, storage, and handling of regulated medical
- The facility shall comply with the provisions of N.J.S.A. 13:1E-48.1 et seq., the Comprehensive Regulated Medical Waste Management Act, and all rules promulgated pursuant to the aforementioned Act, including, but not limited to, N.J.A.C. 7:26-3A.