AFL 20-84 From the California Department of Public Health
November 4, 2020
TO: Skilled Nursing Facilities
SUBJECT: Infection Prevention Recommendations and Incorporation into the Quality and Accountability Supplemental Payment (QASP) Program
AUTHORITY: Assembly Bill (AB) 81 (Chapter 13, Statutes of 2020)
AB 2644 (Chapter 287, Statutes of 2020)
All Facilities Letter (AFL) Summary
This AFL informs skilled nursing facilities (SNFs) about the California Department of Public Health’s (CDPH’s) infection prevention recommendations and the incorporation of infection prevention and Coronavirus Disease 2019 (COVID-19) mitigation requirements into the QASP.
As California continues to protect the health and safety of residents and health care personnel (HCP) in SNFs, COVID-19 mitigation efforts remain important. CDPH acknowledges the need for a more focused infection prevention program as well as a full-time infection preventionist (IP) as stated in AFL 20-52, due to the breadth of activities an infection prevention and control (IPC) program must include.
The importance of the IP is further highlighted by the recent chaptering of AB 2644 that directs SNFs, effective January 1, 2021, to have a plan in place for infection prevention quality control, ensure all HCP receive infection prevention and control training on an annual basis, and have a full-time dedicated IP. Because of the importance infection prevention programs play in the quality of care in SNFs, CDPH is incorporating infection prevention into the SNF QASP Program, subject to the stakeholder process and contingent upon federal approval.
CDPH and the California Department of Health Care Services (DHCS) implement the QASP program in partnership to improve the quality of care in SNFs. CDPH’s Center for Health Care Quality assesses and scores facility quality of care so that DHCS can use these scores to issue incentive payments to SNFs that achieve certain quality benchmarks. The quality benchmarks are based on performance measures that have been developed and agreed upon, in consultation with interested industry stakeholders, as indicators of quality.
AB 81 provides state authority to incorporate COVID-19 mitigation efforts into the QASP Program and create incentives for facilities to comply with All Facility Letter (AFL) requirements related to COVID-19, including implementation of effective infection control practices. Contingent on federal approval, AB 81 allows:
- An additional performance measure based upon a facility’s compliance with any requirements related to the COVID-19 Public Health Emergency described in AFLs issued by CDPH to be considered in assessing quality scores.
- Beginning with the rate period of August 1, 2020 – December 31, 2020, and for subsequent rate years, a facility’s receipt of the annual increase in the weighted average Medi-Cal reimbursement rate may be conditioned on the facility’s good faith compliance with any requirements in AFLs issued by CDPH that are related to the COVID-19 Public Health Emergency declared pursuant to Section 247d of Title 42 of the United States Code on January 30, 2020, and any renewal of that declaration.
CDPH has developed recommended guidelines for an IP to support effective IPC practices for mitigating infections from COVID-19 and other potential pathogens. Recommendations include training standards for initial and continuing education, regular IP functions and activities, as well as the IPC program.
CDPH Recommendations for Infection Prevention and Control
Training and Continuing Education
It is important that each SNF’s IP have training in fundamental IPC principles to effectively perform the IP duties. Ongoing education is necessary to remain aware of new information, trends, best practices, and to refresh existing knowledge. The designated IP (or both IPs if there are two part-time staff designated) should complete their initial IP training within 90 calendar days of hire if the IP is an existing SNF employee who was recently designated to this role, initial training should occur within 30 calendar days of designation. An existing IP who has not completed initial IP training must complete the training no later than January 1, 2021.
The initial training should include the following topic areas and include a minimum of 14 hours:
- Role of the Infection Preventionist
- Infection Prevention Plan
- Standard, Enhanced Standard, and Transmission-Based Precautions
- Hand Hygiene
- Injection Safety
- HAI Prevention (e.g., Respiratory, BSI, UTI, Scabies, CDI, MDRO)
- Infection Surveillance
- Cleaning, Disinfection, Sterilization, and Environmental Cleaning
- Antibiotic Stewardship
- Laws and Regulations (e.g. reporting requirements)
- Preventing Employee Infections
The IP should complete 10 hours of continuing education in the field of IPC on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association.
Infection Preventionist Functions
The function of the IP may vary within SNFs based on the operational structure of the facility. The IP should have the autonomy to make recommendations and implement facility policies to support infection prevention and control adherence. The following functional roles are recommended to be included in the duty statement of staff serving as the IP.
IPC Program Management
- Infection prevention program
- Consult in the development and implementation of the infection prevention program
- Evaluate the effectiveness of the IP program and modify as needed
- Actively participate on the IPC committee
- Develop an annual surveillance plan based on the population served, services provided, and analysis of surveillance data 
- Conduct surveillance using epidemiological principles
- Evaluate and modify the surveillance plan as necessary
- IPC policies and protocols
- Consult in the development and assist with the implementation of IPC policies and protocols
- Communicate IPC information and data to various committees within the facility and HCP
- Develop IPC training
- Assess learning needs and develop training for SNF residents and HCP
- Create educational goals, objectives, and strategies using learning principles and available educational tools and technology
- Conduct training for SNF residents, HCP, engineering staff, housekeeping staff, food service staff, volunteers, and others who enter the SNF on a regular basis
- Conduct adherence monitoring to:
- Provide feedback to HCP and reinforce training concepts
- Evaluate the effectiveness of educational programs and modify if needed
- Consult in the development and implementation of policies and procedures that meet the criteria below:
- Ensure compliance with regulatory and mandatory reporting requirements at the local, state, and federal levels.
- Ensure compliance with COVID-19 and other testing requirements
- Facilitate compliance with regulatory standards among residents and HCP
- Consult in the modification of policies and procedures as needed to meet the criteria above and/or to incorporate current infection control standards
Performance Improvement (PI)
- Use various PI methodologies as a means of enacting change
- Develop policies and procedures for PI measures
- Consult in the development of policies and procedures that define and investigate PI measures
- Ensure that resident needs and rights are considered in the development of processes
- Incorporate IPC process and outcome measures into the Quality Assurance and Performance Improvement (QAPI) program.
- Modify policies and procedures for PI measures as needed
- Participate in PI committees, teams, and initiatives as needed
- Provide consultation to occupational health personnel in the following areas:
- Occupational health policies and procedures related to IPC
- Risk of occupational exposures to infectious disease
- Rates and trends of occupational exposures
- Work restrictions and recommendations related to communicable diseases or following an exposure
- Assist with immunization and screening programs as needed
Infection Prevention and Control Programs for Non-Certified SNFs
To assist in mitigating future outbreaks in healthcare facilities, CDPH is encouraging non-certified SNFs to comply with Title 42 of the Code of Federal Regulations (CFR). Title 42 CFR section 483.80 requires certified SNFs to develop and implement an infection prevention and control program that includes the following elements:
1. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based on a facility assessment following accepted national standards
2. Written standards, policies, and procedures for the program, which must include, but are not limited to:
- A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility
- When and to whom possible incidents of communicable disease or infections should be reported
- Standard and transmission-based precautions to be followed to prevent spread of infections
- When and how isolation should be used for a resident; including but not limited to:
- The type and duration of the isolation, depending upon the infectious agent or organism involved
- A requirement that the isolation should be the least restrictive possible for the resident under the circumstances
- The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease
- The hand hygiene procedures to be followed by staff involved in direct resident contact
3. An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use
4. A system for recording incidents identified under the facility’s IPC program and the corrective actions taken by the facility
Having actionable data is vitally important to preventing and controlling infections. The National Healthcare Safety Network (NHSN) Long-term Care Facility Component provides long-term care facilities with a customized system to track infections and prevention process measures in a systematic way. Using a tool such as NHSN for tracking and routinely monitoring this information allows facilities to identify problems, improve care, and determine progress toward national healthcare-associated infection goals.
Adopting Best Practices
CDPH encourages all SNFs to adopt best practices to prevent and control infections within the facility using nationally recognized standards.
IP Financial Incentives
Annual Rate Increase
SNF IPs must meet IP training recommendations by the start of the 2021 rate year and continue to be in compliance with training and guidance thereafter. CDPH will monitor for compliance during SNF mitigation surveys. Failure to follow guidance may result in a facility’s ineligibility for an annual increase in the weighted average Medi-Cal reimbursement rate, contingent upon federal approval.
CDPH will measure IP training on a pass/fail basis in the QASP calculation. A SNF will not get points towards the quality measure for QASP unless compliance with IP training guidance is demonstrated. CDPH will continue to verify SNF compliance throughout the performance period related to the April 2022 QASP awards, beginning on January 1, 2021. The new measure will be included in the applicable performance period for the April 2022 awards, contingent upon federal approval.
Currently, the QASP Program is scheduled to sunset December 31, 2022.
DHCS and CDPH will work collaboratively with stakeholders to develop a successor supplemental payment or similar quality-based program. Conducting ongoing IP activities may be considered in the development of the quality measure.
For questions regarding the QASP Program, please contact the QASP Program at QASP@cdph.ca.gov.
Original signed by Heidi W. Steinecker
Heidi W. Steinecker