The manual includes a detailed table of contents and numbered tabs for ease in finding specific policies. The manual format includes: The Infection Control Program; Surveillance of Infections; Infection Control Education; Isolation; Employee Health; Patient Care Policies; Departmental Policies; OSHA Exposure Control Plans for Bloodborne Pathogens and TB; Performance Improvement; Bioterrorism; and References.

Table of Contents

INFECTION CONTROL PROGRAM

Infection Control Program Overview

Job Description – Infection Control Practitioner

Infection Control Competency Assessment

Infection Control Committee

Authority of the Infection Control Committee

Sample Minutes Form

SURVEILLANCE OF INFECTIONS

Infection Control Surveillance

Healthcare-Associated Infection Summary Report by Resident Days

Infections by Device Days

Line Listing of Resident Infections

Definitions of Infections for Surveillance Activities

Infection Control Plan

Surveillance Plan

Reportable Diseases

Outbreak Investigation Form

Healthcare-Associated Infections and Sentinel Events

Healthcare-Associated Infections Reviewed as Sentinel Events

Influx of People with Infectious Diseases

INFECTION CONTROL EDUCATION

Infection Control Orientation and Inservices

Infection Control Orientation Outline

OSHA Bloodborne Pathogens Standard Employee Training Outline

Tuberculosis Employee Training Outline

Resident and Family Education for Infection Control and Infectious Diseases

ISOLATION FOR COMMUNICABLE DISEASES

Standard Precautions

Contact Precautions

Droplet Precautions

Compliance Monitoring

Staff Self-Evaluation of Infection Control Practices

Monitoring Compliance with Infection Control Policies

Handling and/or Disposing of Used Needles

Using Gloves

Clostridium Difficile

Methicillin-Resistant Staphylococcus Aureus (MRSA)

Vancomycin-Resistant Enterococcus (VRE)

EMPLOYEE HEALTH

Physical Assessment

Annual Tuberculosis Assessment (for use with staff who are PPD positive)

Reporting Employee Infections

Employee Infection Record

Summary of Important Recommendations and Work Restrictions for Personnel with Infectious Diseases

Criteria for Determining Exposure to

Communicable Disease

Management of Accidental Exposure to

Communicable Diseases

Influenza Vaccine Informed Consent Form

Hepatitis B Immunization Program

Information on Hepatitis B and the Vaccine

Hepatitis B Immunization Consent or Declination

Tuberculosis Screening for Employees

Frequently Asked Questions: Tuberculosis and the PPD Tuberculin Skin Test

Post-Exposure Evaluation and Follow-Up

Bloodborne Pathogens Post-Exposure Evaluation and Follow-Up

Bloodborne Pathogens Post-Exposure Evaluation/ Healthcare Professional’s Written Opinion

Recommendations for Hepatitis B Prophylaxis Following Percutaneous or Permucosal Exposure

Potential HIV Exposure

Consent for HIV Antibody Blood Test and Release of Information

Vaccine Recommendations

Pregnant Personnel

PATIENT CARE POLICIES

Animals in the Long Term Care Facility

Cleaning, Disinfection and Sterilization

Environmental Sampling

Feeding Syringes

Hand Hygiene

Ice Chests and Ice Machines

Immunizations: Influenza (Flu) Vaccination of Residents, Staff, and Volunteers

Immunizations: Pneumococcal Vaccination (PPV) of Residents

Immunizations: Adverse Reactions

Infectious Waste Management

Intravenous Therapy

Use of Oxygen

Care of Resident with Pediculosis (Lice)

Personal Hygiene

Pest Control

Care of Resident with Scabies

Collection of Specimens

Use of Thermometers

Suctioning and Care of Tracheostomies

Nasogastric/Gastrostomy Tube Feeding

Urinary Catheters

Visitors

Prevention of Wound Infections

Wound Care/Treatment Guidelines

Wound Care Procedure for Major Wounds

DEPARTMENT POLICIES

Beautician/Barber Services

Dietary Services

Housekeeping Services

Laundry Services

Maintenance Department

Vending Room (Canteen)

OSHA BLOODBORNE PATHOGENS REGULATIONS

Bloodborne Pathogens Model Exposure Control Plan (ECP)

Program Administration

Employee Exposure Determination

Methods of Implementation and Control

Standard Precautions

Exposure Control Plan

Engineering Controls and Work Practices

Personal Protective Equipment

Housekeeping

Laundry

Labels

Hepatitis B Vaccination

Post-Exposure Evaluation and Follow-up

Administration of Post-Exposure Evaluation and Follow-up

Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

Employee Training

Recordkeeping

Training Records

Medical Records

OSHA Recordkeeping

Sharps Injury Log

Sample Sharps Injury Log

Employee Input about Engineering and Work Practice Controls

TUBERCULOSIS CONTROL PLAN

Tuberculosis Control Plan

Tuberculosis Risk Assessment

Elements of a Tuberculosis Infection Control Program

Employee Tuberculosis Skin Testing Summary

Immunization and TB Skin Testing Record

Annual Tuberculosis Assessment

PERFORMANCE IMPROVEMENT

Compliance Rounds

Infection Control Rounds

Compliance Rounds Forms:

Foley Catheters

Laundry and Linen Handling

Tube Feeding

Cleanliness and Sanitation

Safer Sharps and Sharps Disposal

Standard Precautions

Documentation of Infections

Dressings/Wound Care

APPENDIX A: BIOTERRORISM PLAN

Introduction

Section I: General Recommendations for a Bioterrorism Event

Section II: Agent-Specific Recommendations:

• Anthrax
• Botulism
• Plague
• Smallpox

Appendix 1: Websites Relevant to Bioterrorism Readiness

Appendix 2: Other Sources of Information