Monday, November 15, 2021
EPIC Newsletter
For Arizona SNFs - Emergency Preparedness Infection Control
Check out our DR EPIC Helpline!
To submit questions, email the DR EPIC online Help Center at EPIC@azhca.org. You can also call the DR EPIC phone Helpline at 602-241-4644 and we will assist you.
AHCA/NCAL FREE Infection Control Training

The Arizona Health Care Association Emergency Preparedness Infection Control (EPIC) program is offering free infection control training courses. These trainings will be for one person per facility for each of the two trainings. If you are interested in receiving one of these trainings, click on the links below to complete the interest form. Once we have your contact information, you will receive an email from us (AHCA) with instructions on how to register for the course directly through AHCA/NCAL and a discount code to use when checking out. By using the discount code provided in the email there will be no registration fee at checkout.

Course Titles and Descriptions

  • AHCA/NCAL Infection Preventionist Specialized Training: This is an updated version of the Infection Prevention Control Officer (IPCO) training. Through this program, individuals will be specially trained to effectively implement and manage an Infection Prevention and Control Program in a nursing center. This updated version incorporates information from the COVID-19 pandemic, the most recent regulatory requirements as well as sections on Candida auris, Multi-Drug Resistant Organisms (MDROs), and Enhanced Barrier Precautions (EBP). Additionally, there is an entire section on how to get an effective water management program running in your center.  

  • AHCA/NCAL Infection Prevention and control in the Post-Covid-19 World: This course will review how COVID-19 spreads, how to track and report the illness including the regulatory requirements for infection prevention and control. It will review the basics of infection prevention and control practices and will look at the future of infection prevention and control. The course will describe the process for cohorting and utilizing testing to inform cohorting practices. It will look at how to conduct self-assessment processes to continually evaluate and improve the infection prevention and control program in long term care centers. Lastly, the course will review the process and necessity of screening practices and notifications to residents, families, and their representatives including the importance of communication.
Be Aware of Top
Ten OSHA Violations

Compliance is not just a game of avoiding citations. Compliance is an important step in protecting your team and our residents. Knowing where enforcement is focused can help you dedicate limited resources towards the hazards deemed most critical by regulators. Here are the Top 10 Most Frequently Cited Standards by the Occupational Safety and Health Administration (OSHA) for Fiscal Year 2020 (Oct. 1, 2019, to Sept. 30, 2020).

  1. Fall Protection, construction (29 CFR 1926.501)
  2. Hazard Communication Standard, general industry (29 CFR 1910.1200)
  3. Respiratory Protection, general industry (29 CFR 1910.134)
  4. Scaffolding, general requirements, construction (29 CFR 1926.451)
  5. Ladders, construction (29 CFR 1926.1053)
  6. Control of Hazardous Energy (lockout/tagout), general industry (29 CFR 1910.147)
  7. Powered Industrial Trucks, general industry (29 CFR 1910.178)
  8. Fall Protection–Training Requirements (29 CFR 1926.503)
  9. Eye and Face Protection (29 CFR 1926.102)
  10. Machinery and Machine Guarding, general requirements (29 CFR 1910.212)

For more information on this visit https://www.osha.gov/top10citedstandards
Flu Season is Upon Us

The 2021-2022 flu season is officially here! The best way to reduce your risk from seasonal flu and its potentially serious complications is to get vaccinated every year. This year all flu vaccines will be quadrivalent- which is designed to protect against four different flu viruses. Flu vaccines and COVID-19 vaccines (including booster doses) can be given at the same time. Learn more about how you can help prevent the spread of respiratory illness like flu here.
November is C. diff Awareness Month

For the month of November, the CDC observes C. diff awareness month!

Clostridioides difficile (C. diff) is a germ that causes severe diarrhea and inflammation of the colon. According to the CDC, it is estimated to cause almost half a million infections in the United States each year and an estimated 29,300 deaths. C. diff awareness month is an opportunity to highlight the importance of protecting yourself and your family and stopping the spread of this deadly infection. Be aware, be smart and educate yourself about antibiotic prescribing and use.
Join the Infection Preventionist Call

Each month EPIC hosts a call targeted to infection preventionists in skilled nursing facilities. If you are interested in participating please send your contact information to Kay Huff and we will send you a link to the call. The call will be held Thursday, November 18th at 1:00 pm.

October IP Call Summary
On the October monthly Infection Preventionist (IP) call, Dr. Peter Patterson gave a brief presentation on Getting to the Truth About Antibiotics. He stated that the root cause of widespread antibiotic resistance is rampant overuse of antibiotics. The most common overuse is residents receiving antibiotics to treat infections they do not actually have. The most common non-infections being inappropriately treated are: “Non-UTI” and “Non-Pneumonia”. This inappropriate use most often happens because a positive diagnostic test (urine culture or chest X ray) is misinterpreted as indicating a treatable infection. Doctor Patterson then reviewed the standard UTI and Pneumonia case definitions and showed that each requires a positive clinical picture in addition to a positive diagnostic test. His final point was reviewing the goals of an effective antibiotic stewardship program:
  • To measure antibiotic prescribing by syndrome (eg. UTI, Pneumonia)
  • To make visible antibiotic overuse through proper data collection
  • To minimize the overdiagnosis/overtreatment of:
  1. Asymptomatic bacteriuria as if it was a UTI
  2. A positive chest X ray as if it was Pneumonia
  • To enhance the decision-making of doctors and nurses

Going forward, Doctor Patterson will be a regular participant in the monthly IP calls and is available to answer questions from the EPIC helpline (602-241-4644) or email EPIC@AZHCA.org.
New Survey Focus on Evacuation Procedures (E-0020)
Based on information that we have received from providers who have recently been surveyed, we now know that surveyors will be focusing on a specific element of E-0020 pertaining to evacuation procedures. In a revised version of Appendix Z issued in April of 2021 (click here) new language has been added to the regulations in red text under E-0020 stating that facilities must "address a situation where a patient/resident refuses to evacuate" and how the facility would handle this type of incident.
 
Essentially, this means that facilities need to address this scenario in their Emergency Operations Plan (EOP) by adding written instructions on how this type of situation would be handled. The premise of this requirement is to help ensure that no patient/resident be left behind during an emergency. Adding some simple guidance in the EOP or evacuation policy on how facility staff can persuade a defiant patient/resident to cooperate during the evacuation process is going to be a compliance element surveyors will be verifying in the future. Contact Stan Szpytek, Life Safety / Disaster Ready Consultant at Stan@azhca.org or (708) 707-6363 regarding this important matter.
FDA Investigating Certain Imported Medical Gloves
 
Certain overseas companies have been issued warning letters by the FDA due to their medical examining gloves appearing to have been reprocessed, cleaned or recycled and sold as new. The FDA issued an Import Alert 80-04 (fda.gov) on October 26 listing the companies and their products subject to Detention without Physical Examination under the Import Alert. Medical providers and healthcare facilities should not use or purchase imported gloves included in the list. Purchased gloves appearing to be visibly soiled, are a different color, appear to have been used or otherwise seem to be fraudulent, should be reported to the agency by email to fda-covid-19-fraudulent-products@fda.hhs.gov.
Federal Respiratory Protection Standard 29 CFR 1910.134 is a Top Priority

Compliance with U.S. Federal Respiratory Protection Standard 29 CFR 1910.134 is mandatory, even for the use of N95s. This standard includes a variety of required tasks, some are one-time, some are annual and some are subject to policy or changes in the employee.

In brief, you must have:
  • A written Respiratory Protection Program (RPP)
  • A completed OSHA Respirator Medical Evaluation Questionnaire for each employee who will wear a respirator (e.g. an N95)
  • Signed Medical Release from a Physician or Licensed Healthcare Professional (PLHCP), who reviewed the Questionnaire (and sometimes examined the employee)
  • Annual Fit Testing of each employee on every make/model/size respirator they will wear
  • Annual Respirator Training for each employee with focus on the limitations, obligations, hazards, care and use of the respirator they will wear

As of 2020, violations of the Federal Respiratory Protection Standard were the #3 issued citation in the USA. OSHA proposed $83,000 in fines to a healthcare facility for failing to protect workers from coronavirus hazards in Bloomingdale, Illinois. OSHA determined that this facility required employees to wear N95 filtering face piece respirators while entering the quarantine area and providing care to suspected coronavirus positive residents. However, it failed to ensure proper use of respirators and fit test all employees to ensure an effective seal, as required. "Simply wearing a respirator is not enough. Employers must ensure respirators fit correctly and maintain a face-to-face piece seal to ensure they protect the user from the spread of infectious diseases," said OSHA Area Director Jake Scott. "After more than a year of fighting this pandemic, employers should know the procedures to minimize workers' risk of exposure and take every precaution." For the entire news release from OSHA on this violation see: 
After Action Report Template- COVID-19 Public Health Emergency

Skilled Nursing Facilities are able to utilize their management of the COVID-19 Public Health Emergency (PHE) for both the 2021 and 2022 survey cycles in accordance with a CMS memo issued on June 21, 2021 revising the Emergency Preparedness requirements cited in Appendix Z. Appropriate documentation including the development of a comprehensive after-action report (AAR) and improvement plan are needed to receive an equivalency to the annual community-wide, full-scale exercise requirement for each of the yearly survey cycles. This means that a facility's management of the PHE with their Emergency Operations Plan (EOP) excuses them from the annual, full-scale exercise requirement. SNFs are still required to complete an "exercise of choice" in each of the two years (2021 and 2022) in addition to the community-based full scale exercise or utilization of the COVID-19 PHE exemption as outlined in the memo. 
 
AHCA/NCAL has developed an AAR / Improvement Plan template that can be used to appropriately document a facility's response to the COVID- 19 PHE. Without proper documentation, surveyors may not give a facility credit for the community-wide, full-scale exercise equivalency. It is critical for facility's to complete the template and not simply present the document to surveyors without customization. For additional information, contact the Disaster Ready Team- Stan Szpytek at stan@azhca.org or Gil Damiani at gild@azhca.org with your questions or comments.
Remember the DHS Bed Poll!

Is your facility registered in EM Resource to enter data in the Bed Poll? In conjunction with the MOU and evacuation plan, the AZ Bed Poll is still available and allows those entering data to list any COVID-19 restrictions or conditions a facility is willing and able to accept other facilities residents. 
Bed Poll Forms
Questions? Call or email EPIC Consultant Gil Damiani at gild@azhca.org or call 480-682-7760.
Infection Prevention Personnel and Emergency Planning
 
CMS has made it clear that infection prevention personnel should be part of a skilled nursing facility's emergency planning process. Memos issued by CMS over the course of the last year updating the Emergency Preparedness Rules of Participation (Appendix Z) address this matter. Emergency Operations Plans (EOP) are required to be developed in accordance with the identified threats and perils that can potentially impact a facility. Emerging Infectious Diseases (EID) and pandemic most certainly have been identified as a potential hazard by every facility. Therefore, personnel who specialize in this particular area of facility operations like an Infection Preventionist should be part of the emergency planning team. 

AHCA/NCAL has developed a summary document that clarifies this important point on page 2 (bullet 2)- here is a link to this resource.
COVID-19 Emergency Management Still Equates to CMS Exercise Equivalency into 2022

Skilled nursing facilities must ensure that they meet all of the Emergency Preparedness exercise requirements each survey cycle in accordance with E-039. This includes participation in a full-scale, community-based exercise as well as an additional exercise of choice like a tabletop exercise conducted annually during each survey cycle. The current COVID-19 Public Health Emergency (PHE) provides facilities with an equivalency to the full-scale, community-based exercise into 2022 as long as the facility is still managing the incident with its Emergency Operations Plan (EOP). This means that proper documentation must be developed to illustrate to surveyors that the SNF is still managing an active, real-world incident. A CMS memo dated September 28, 2020 and revised June 21, 2021 provides additional clarification and explains the exercise equivalency in detail. Contact Stan Szpytek, DR/EPIC Consultant at stan@azhca.org with any questions.
Emergency Preparations and the AzCHER Memorandum of Agreement

Effective emergency preparedness efforts must include a viable evacuation plan. The fact that infection control procedures must still be adhered to complicates the process even more.  The thought of evacuating an entire facility is a difficult undertaking.  Several tools are available to SNFs to assist in the planning effort. The Arizona Coalition for Health Care Emergency Response (AzCHER) Memorandum of Understanding (MOU) was revised in 2020. Once you have signed the AzCHER MOU, it allows you to begin discussions with other facilities as possible relocation sites. Participation in the Az Bed Poll and MOU are voluntary and not required by CMS, however, participating in both comply with 4 E-Tags.  E-Tag E0009 “Process for EP Collaboration’ is directly related to a facility’s participation in their respective Regional Coalition. E-Tag 0022 Policy & Procedures including Evacuation, E-Tag 0025 Arrangements with Other Facilities, E-Tag 0034 Sharing Information on Occupancy Needs.
Please review the following links and make sure your facility has completed the updated MOU version. Please make sure your facility has registered as an AzCHER member/participant, as it is a prerequisite to update your MOU.

Any/all MOUs signed prior to January of 2019 are no longer valid. Please review this list of current MOU signatories.

If you have not signed an MOU with AzCHER or completed one prior to January 2019 please complete this MOU.
Don’t forget to utilize our DR EPIC website for valuable infection prevention resources! Go to: EPIC.DisasterReadyaz.org to explore these tools.
Questions? Contact EPIC@azhca.org |This program is funded by ADHS
The Disaster Ready Emergency Preparedness Infection Control (DR EPIC) program provides education and technical assistance for skilled nursing providers throughout the state. Individual providers will need to exercise their independent discretion in how to apply this information and technical assistance to the unique operation of each facility. For that reason, a facility’s of its professional judgment and due diligence in utilizing the program for infection control and risk management practices is solely within the facility’s control for which it is entirely responsible. 
Copyright 2021.