Increased Focus on Infection Prevention and Control in New CoPs

In the current COPs (Conditions of Participation), infection prevention and control procedures are addressed briefly.  However, in the new CoPs, starting January 2018, this will change.  There are three standards in Condition 484.70.  These standards address prevention, control and education.

According to comments suggested to CMS, they need to define the program information needed to comply.

RESPONSE:  “Federal and state agencies, such as the CDC and state departments of health, as well as accreditation organizations and national professional organizations, have all developed infection prevention and control standards of practice.  There is a wide variety of information on this subject available for HHAs to choose from in creating their own programs, and we do not believe that it is appropriate to specify which standards HHAs must use.  We would expect an HHA to be able to identify the source of the standards it selects and be capable of explaining why those standards were chosen for incorporation into the HHA’s infection prevention and control program.”

Below we will review the three standards in further detail:


The home health agency (HHA) must maintain and document an infection control program with the goal of preventing and controlling infections and communicable diseases.  The standard states that the HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


The second standard addresses control.  According to it, the HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program.

The infection control program must include:

(1) A method for identifying infectious and communicable disease problems.

(2) A plan for the appropriate actions that are expected to result in improvement and disease prevention.

According to this standard, tracking, reporting, and prioritizing those at risk for Infections are necessary to identify patterns of infections, and proactive measures for prevention of infection.  Infections among patients, staff, volunteers, and students will be reported and analyzed to identify patterns of infection occurrence(s).  This will aid in reducing the occurrence of infection acquired by patients while receiving home care and thereby, improve patient outcomes.  It will help to prevent and control the spread of infection. Finally, changes in the scope and type of infections as a result from both tracking infections and/or new services provided are evaluated and addressed.


The final standard addresses education.  The HHA must provide infection control education to staff, patients, and caregiver(s).


“We do not believe that it is appropriate to specify the form or content of patient and caregiver education regarding infection prevention and control.

The education, both in content and format, must meet the needs of the patient and caregivers.

This means different things for different individuals. Some understand better with written instructions while others understand better with in person demonstrations and still others understand better with video instructions. The form and content of the education efforts need to meet the needs of the individual being educated.

We would expect HHAs to document these efforts in a manner that suits the workflow of the HHA and successfully demonstrate upon survey that the requirement was met.”

Education is Key for Optimum Infection Control and Prevention

Educate! Educate! Educate!  We cannot stress enough the importance of education when it comes to ensuring optimum infection control and prevention.  During every patient visit it is critical to educate and/or reinforce infection control practices.  Infection control handouts should be provided frequently, not just at the time of admission.

Also, it is critical to conduct frequent supervisory visits with staff.  These sessions should focus on infection control practices.  Frequent in-services should cover all policies and procedures, the results of supervisory visits, and infection surveillance reports and when to complete them.  At a minimum, competency should be conducted annually.  Finally, QAPI – infection control surveillance and tracking should be done.

5 Star Consultants Can Help Ensure HHA Success

Our team at 5 Star Consultants brings decades of experience to every project.  Educating your team about the new CoPs is no exception.  There are many ways we will educate your team about infection control and prevention.  For example, we will work with your staff to build an infection surveillance process, develop prevention areas regarding hand hygiene techniques, environmental cleanliness, personal hygiene and many other key subjects.  We will train all home health field personnel on infection control during orientation, annually and when deficiencies are found.

For further information regarding training on CoPs as well as many other home health and hospice topics, please contact us at [email protected] or 866-428-4040.

Southern Web SupportIncreased Focus on Infection Prevention and Control in New CoPs
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