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INSERT FACILITY NAMEInfection Prevention and Control Program Plan insert yearDemographics Scope of ServiceInfection Prevention and Control (IPC) Program Purpose and design:The purpose of the Infection Prevention and Control (IPC) Program is to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPC program will establish a facility wide system for the prevention, identification, investigation, reporting, and control of communicable diseases and infections among residents, staff, and visitors. The success of the IPC program is defined by its effectiveness in achieving goals. The priorities/goals of the program are determined by the annual risk assessment. The risk assessment looks at the resident population, risks, services provided, and prevention processes in action. The risk assessment is evaluated in order to identify and assign priorities. Once priorities are identified, goals with measurable objectives and strategic action plans will be created. Goals will be reviewed throughout the year to monitor progress. This document is the Infection Prevention and Control Plan and is designed to document the goals and objectives of the program and assist in determining strategies for reduction of risk as identified in the quantitative risk assessment. This document may be updated throughout the year as initiatives are completed and/or new risks are identified. The IPC annual review will provide the evaluation process to determine if objectives were met.IPC Authority and Responsibility:The IPC Program has both authority and responsibility based on function and anticipated outcome. The program is monitored, and priorities are set by ______________. The IPC plan and risk assessments are reviewed annually and as necessary by __________. All policies are developed utilizing evidenced based resources and infection prevention and control measures that have demonstrated a positive impact on process and prevention of health-care associated infections. The Infection Prevention and Control Staff: List staff names and titlesServices: The IPC staff duties are multifaceted with focus to ensure resident and staff safety by means of the following, but not limited to:Education and trainingSurveillance - Develop, analyze, manage, and report dataProvide consultation and education when necessary to healthcare workers, residents, and visitors Recommend and develop policies and procedures governing control of infections and communicable diseases with evidence-based recommendations from regulatory and recommending bodiesIntervene directly when there is a risk of transmission of infectious diseases and/or unprotected exposure to pathogensProduct evaluationEnvironmental review and observation of infection prevention practicesTo participate and integrate infection prevention strategies within the facilities programsRespond and provide liaison activities with state and local health authorities related but not limited to:Outbreaks Management of residents related but not limited to: Influenza, emerging pathogens, communicable diseases in the community, bioterrorism, and other potential threatsWhen appropriate will participate in the review of sentinel events and implement any necessary processes and proceduresInfection Prevention and Control Committee (Note: Change name of committee/group that will participate in review/oversight of plan and outcomes)Insert who chairs the committee and the members are.The responsibilities for oversight and management of the INSERT FACILITY NAME IPC program is assigned to the INSERT COMMITTEE NAME FROM ABOVE, though all staff have the responsibilities for preventing and controlling infections. An INSERT COMMITTEE NAME Schedule has been established (Attachment A).Reporting Structure: The IPC Plan, initiatives, and data are reviewed annually and as necessary by ___insert the committee name listed in IV, d, i,____.Maine Centers for Disease Control and Prevention (MeCDC): The Department of Infection Prevention and Control in conjunction with __ENTER NAME IF THERE IS ANOTHER PARTY/DEPARTMENT WHO WILL PROVIDE REPORTING FUNCTION_ provide the reporting function for reportable diseases. The Infection Preventionist(s) report communicable diseases that are on the Notification list to the MeCDC immediately by telephone as required. Regulatory and Quality DriversMaine LegislationList any other regulatory bodiesRecommending BodiesIncludes but is not limited to:Centers for Disease Control and Prevention (CDC)Healthcare Infection Control Practice Advisory Committee (HICPAC)Association for Professionals in Infection Control (APIC)Society for Healthcare Epidemiology (SHEA)Guidelines for Design and Construction of HealthCare Facilities American National Standards Institute (ANSI)American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE)American Society for Healthcare Engineering (ASHE)IPC Availability and ResourcesIPs are available during regular business days from ______, Monday through Friday for consultation regarding isolation practices and policies and can be reached at the departmental telephone _______. IPC Policies are available through ____________.IPC Staff MembershipMembership is maintained in the Association for Professionals in Infection Prevention and Control and Epidemiology (APIC/Pine Tree Chapter) at the local and national levels to provide opportunities for education, professional growth and networking. Current staff:List name and qualifications/titles of each staff personPerformance Improvement/Resident Safety/QualityThe IPC program will integrate with any resident safety and quality assurance/Performance Improvement initiatives and committees, including:List any facility Performance Improvement and/or Quality Committee/Teams/GroupsThe IPC program will document all identified IPC incidents, investigations, corrective actions, and outcomes. This will be performed by insert description of process. Focused GoalsThe following table includes IPC focused measurable goals determined by the high-risk priorities of the annual risk assessment. Risk CategoryGoalsMeasurable ObjectivesStrategiesTransmission-Based Precautions – Interventions & Notification________ will notify IPC of actual/potential communicable diseases per IPC policies.? Examples include but are not limited to: Candida aurisCarbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae/and Other targeted organisms (Pseudomonas aeruginosa, Acinetobacter baumannii) (CP-CRE/CRO)List other organisms as appropriateEmergency Preparedness & High Consequence infectious Diseases (includes novel pathogens)IPC collaborates with, institutional and local and state emergency management agencies in the event of emergent events that have impact as related to IPC on resident and staff safety.List who the contacts are and high-level overview of the process.Over the last twenty years the world has faced many High Consequence Infectious Disease (HCID) outbreaks that have traveled from country to country. Recent outbreaks such as SARS-CoV-2 (COVID-19) serve as a reminder that HCID can circulate at any given time. HCID outbreaks generate substantial public health, security, and economic consequences. Planning for these HCID is very important. HCID is defined by as a disease that includes any confirmed or suspected infection with a pathogen that meets either of the following criteria:Pathogens for which all forms of medical waste (including patient excreta, secreta, blood, tissue, tissue swabs, and specimens in transport media) are classified as category A infectious substances (UN2814) by the U.S. Department of transportation; ORA pathogen with the potential to cause a high mortality rate among otherwise healthy people and At least some types of direct clinical specimens pose generalized risks to laboratory personnelKnown risk of secondary airborne spread within health care settings or unknown mode of transmissionNo?routine vaccine exists HCID Plan: insert high level overview of the facilities HCID plan.Outbreak InvestigationsOutbreaks are investigated and control measures are implemented when appropriate.INSERT NAME OF RESPONSIBLE PERSON’s TITLE will notify the MeCDC and work with the MeCDC to implement any actions necessary for resident and staff safety. Reference facility policyEmployee Health and Safety_____provides assessment, prophylaxis, and follow up of exposed healthcare workers, as well as evaluation of personnel who are injured or become ill on the job, initial health evaluations and immunizations for new employees, and Tuberculosis screening for personnel. Safe Injection Practice: insert high level overview of practices and prevention initiativesSharps Safety: insert high level overview of practices and prevention initiativesAn exposure control plan is developed to address potential hazards to bloodborne pathogens for staff and residents.Exposure Incidents: Exposure of personnel and residents to communicable diseases such as tuberculosis, chickenpox, meningococcal meningitis, pertussis, bloodborne pathogens and others are promptly investigated. Investigative procedures include development of a contact list and a definition of exposure, interview of personnel and residents on the contact list, determination of the susceptibility of each exposed person to the infection of interest by history and/or serologic testing, referral of exposed susceptible personnel to _______ for evaluation, prophylaxis and follow-up, furlough of exposed susceptible personnel who may be incubating an infection and potential isolation of exposed susceptible residents. For further ________.Communicable Disease Management: High-level description of process for managing communicable illnesses amongst staff (i.e. identification, notification, work restriction).Respiratory Protection Program: High-Level description of the respiratory protection programEnvironment of CareEnvironmental cleaning (EC) is a fundamental principle of preventing infection. Both porous surfaces (e.g., cloth) and nonporous surfaces (e.g., metal door handles) in resident rooms are highly susceptible to bacterial contamination with dangerous pathogens, including?Clostridioides difficile, and antibiotic-resistant organisms such as methicillin-resistant?Staphylococcus aureus?(MRSA), vancomycin-resistant?enterococci?(VRE), and multiple species of?Acinetobacter?(Acinetobacter?spp.). Hard, nonporous surfaces, which include common items such as furniture, bed rails, and medical equipment, as well as fixed spaces like floors and bathroom facilities, form part of the environmental reservoir that can lead to significant microbial contamination. A process to decrease the bioburden of potentially transmissible organisms is in place and includes:Non-Critical Equipment: Adequate cleaning/low-level disinfection of non-critical equipment used on multiple residents (i.e. blood pressure cuffs, pulse oximeters) are addressed through policy and procedure. IPC works staff to ensure that non-critical equipment which comes in contact with multiple residents is cleaned/disinfected appropriately between residents, or that single use, disposable equipment may be considered.Routine Cleaning/Disinfection of the environment:Describe high-level overview of routine cleaning process of common spaces, resident rooms, and when a resident is on transmission-based precautions.Biomedical Waste Management: high-level overview of the programHand HygieneHand hygiene practice critical to ensure resident safety. INSERT FACILITY NAME subscribes to INSERT GUIDELINE SUSCRIBED TO. While the ultimate goal is to have 100% compliance, the INSERT YEAR focused goal will be to increase and maintain hand hygiene at ___%. Actions include: Hand Hygiene Auditing (dicusss details)List other hand hygiene compliance initiativesSurveillanceRoutine surveillance of infection prevention practices is crucial to the sustainability of a robust infection prevention program. Surveillance provides the ability to identify opportunities for improvement, as well as track and monitor both process and outcome data. All of this information is vital to determine if initiatives are effective, identify areas to prioritize, and create new prevention/improvement strategies when needed. Rounding allows for real-time educational opportunities with front-line staff as well as collection of compliance data. Rounding support and performance is not a sole responsibility of the IP and should be a practice performed by leadership as well.Rounds and audits performed:Hand Hygiene Auditing:Describe the processNon-Critical EquipmentDescribe the processPersonal Protective EquipmentDescribe the processEnvironment of CareSurveillance of communicable diseases:Describe the process is in place to identify potentially infectious persons at the time of admission.EducationEducation of staff, volunteers, and residents is a vital part of infection prevention. IPs are available to provide ongoing educational programs relating to the prevention and control of infectious diseases and the practice of Infection Prevention and Control according to the standards set forth by the recommending bodies. It is the responsibility of all staff to ensure they complete their annual_____ Infection Prevention and Control training and attend mandatory Infection Prevention and Control educational activities. Supervisors and staff are encouraged to contact an IP regarding the provision of specific in-services. Education includes but is not limited to:List education provided, list if at hire or annually or both:Standard and Transmission-based precautionsBloodborne Pathogens and Exposures ControlSharps and Injection SafetyCleaning and disinfectionList any other education New ProjectsList any new projects for the year that were not a part of the previous year’s IPC PlanUpdatesThe following is a list and description of updates/changes made to the IPC Plan throughout the INSERT YEAR calendar year:Resources / ReferencesThe APIC/JCR Infection Prevention Control Workbook. 2nd Edition and APIC Text Online (ATO)APIC Text of Infection Control and Epidemiology, 4th edition, 2014Insert any applicable resources/referencesAttachmentsAttachment A – IPC Schedule for Reporting and Updating. Schedule may be subject to change based on identified priorities throughout the year. Attachment A: Infection Prevention and Control Function Team Reporting Schedule NOTE: this can be adapted to fit whatever reporting structure is in place i.e. monthly, quarterly, etc.JanuaryFebruaryMarchApril MayJuneJuly AugustSeptemberOctoberNovemberDecember ................
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