The CMS has finalized its new infection control regulations for long-term care, revising a few areas in response to comments while implementing landmark changes to protect increasingly vulnerable resident populations.
For veteran long-term care infection preventionists like Deborah Burdsall, PhD, MSN, RN-BC, CIC, the CMS action was validation of decades of efforts to improve infection control in long-term care (LTC).
“It is so exciting that people are finally really paying attention to infection prevention in long-term care,” she tells Hospital Infection Control & Prevention. “I started looking at long-term care 43 years ago and have been in infection prevention in [the field] for about 30 years. People got tired of hearing me fuss about infection prevention and how the infrastructure had to be improved in long-term care.”
The CMS rule moves firmly in that direction. Though there are several caveats and phased-in requirements, the CMS is essentially requiring long-term care facilities to conduct risk assessments and implement a system “for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, [and] visitors.”1 Moreover, the CMS reports in the final rule that many commenters agreed on the importance of having infection control programs in nursing homes.
“We agree that infection control is very important for residents, as well as the staff and other individuals who work or visit the facility,” the CMS states in the rule. “We believe the requirements that are finalized in this rule will contribute to the reduction in HAIs, which should result in a reduction in physical harm to residents and others, as well as a decrease in the associated healthcare costs.”
Major changes in the delivery of care and aging demographics of the population have led to nursing home residents with high acuity and a commensurate need for more elaborate healthcare.
“We have seen a huge shift in the LTC population over the last 10 years,” Burdsall says. “It has gone from essentially being a residential community to a post-acute environment where you have people transitioning from acute care areas. Infection prevention is so important. It used to be you had people who were older, but essentially stable and living in a home-like environment. Now you have people who are coming out of acute care episodes, whether it be illnesses, post-surgical, hip replacements, knee replacements, wound care [etc]. So, you have people who are healing, and infection prevention is important because they have become more vulnerable.”
Long-term care facilities have long argued they don’t have the resources to fund infection control programs akin to hospitals. The CMS makes some concessions in that respect, but it’s fair to say those arguments are no longer persuasive. Consider this finding by the CDC: Clostridium difficile caused some 115,400 infections with onset in nursing homes in the United States in 2012, comprising nearly one-quarter of all U.S. C. diff cases. Of those, some 8,700 (8%) residents died within 30 days of diagnosis.2
Given that antimicrobial misuse drives C. diff infections and selects out drug-resistant bacteria, the CMS is requiring antibiotic stewardship programs in LTC.
“[W]e are finalizing the requirement for LTC facilities to establish and maintain an [infection prevention program], which must include, among other things, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use,” the CMS states.
Overall the CMS estimates that there are between 1.6 and 3.8 million healthcare-associated infections in LTC facilities annually, resulting in 150,000 hospitalizations and 388,000 deaths. These LTC infections and attendant consequences cost between $673 million to $2 billion annually. Of course, these events go well beyond the numbers, Burdsall reminds.
“There is the economic cost of infections and that spreads across all of this, the people affected, the healthcare organizations,” she says. “But there is also the personal cost of the infection, which can mean loss of life, loss of function and abilities. Having seen people go through infections, it’s terrifying, painful and expensive. Infection prevention and control really has to be looked at from a biological, psychological, sociological, and spiritual aspect of human care. You have to look at it that way -- it’s a human issue. Any type of guidance or regulation that steers people in that direction is important.”
Some suggested in comments that the CMS require certain staffing levels to meet the requirements, but the agency disagreed and said facilities should determine staffing needs based on their infection control risk assessment.
“In this final rule, each facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for it residents competently during both day-to-day operations and emergencies,” the CMS states. “That assessment must include, among other things, the resident population and the care required by that population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present in that population, as well as the staff competencies that are necessary to provide the level and types of care needed by that population.”
In terms of training, the CDC and CMS are exploring opportunities to jointly develop LTC infection prevention training programs. The Association for Professionals in Infection Control and Epidemiology also has training and a certificate for LTC, Burdsall notes.
“It is very encouraging that the CDC and CMS are working together to try to provide [resources] for people who want to work in LTC,” she says. “If you look at how the CMS responded to the comments, they talk about ‘prevention.’ They want to get prevention in there -- it is not just infection control. The other thing that they are really focusing on is that you have to know your [resident] population, what services you are providing, and you have to do a facility risk assessment. That has to be a ‘living’ document. They are really focusing on this mechanism to drive identifying and addressing risk with the programs that you put in place.”
Some commenters on the proposed rule warned the CMS about the negative effects of the hospital approach of isolating a resident – with, for example, MRSA – because people in LTC may greatly benefit from socialization and interaction.
“We agree with the commenter that isolation should only be used when necessary to control the spread of infections and should be the least restrictive as possible to the resident,” the CMS states in the final rule.
IP Role can be Divided
The CMS also moved away from requiring a single designated IP, saying “we agree that LTC facilities should have the flexibility to determine if more than one individual should be designated to be responsible for the facility’s IPCP. … Depending upon the facility, we understand that there is a substantial variation in the amount of resources required for the [IP program], especially the amount of time the IP needs to devote to those responsibilities. For some facilities, especially small and rural LTC facilities, it may not be feasible or even necessary to have one staff person devote a substantial amount of their time to [the program] or have it be their primary responsibility.”
Again, the facility risk assessment should inform this decision, the CMS states, “In addition, we are finalizing the requirement that the IP work at the facility at least part-time.”
Overall, the major theme is that LTC is not an island, but a part of an interactive continuum of care, where risk is assessed and addressed at facilities that are in communication with each other.
“I am very excited about the comments and the careful, thoughtful responses by CMS,” Burdsall says. “I think this is realistic. The barriers we fought for years but are finally coming around. The thing I like about this document is that there is flexibility to focus on evidence-based practice.”
- CMS. Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities. Fed Reg Oct 4, 2016.
- Hunter J, Mu Y, Dumyati, M., et al. National Estimates of Incidence, Recurrence, Hospitalization, and Death of Nursing Home-Onset of Clostridium difficile Infections — United States, 2012. CDC 64th Annual EIS Conference. Atlanta: April 20 – 23, 2015