With the release of the CMS mandate requiring the use of EBP in certain circumstances, we offer information related to common questions.
CMS developed a Quality in Focus program as a resource for all long-term care facilities across the country. Using Quality in Focus as the foundation, Polaris Group highlights best practices to help mitigate civil money penalties and lower scope and severity citations related to FTag deficiencies. This month we review a new twist to an old regulation – F880 Infection Prevention and Control, under which the new Enhanced Barrier Precaution guidelines are included.
Regulation and Guidance for F880
- §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
- §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements.
- §483.80(a)(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 upon the facility assessment conducted according to §483.70(e) and following accepted national standards.
While the regulation is not new, there are new questions surrounding the correlation between F880 and Enhanced Barrier Precautions (EBP). Since the release of the CMS mandate effective April 1, 2024, requiring the use of EBP in certain circumstances, we offer information related to commonly asked questions.
Six common questions asked and answered by Polaris Consultants
- Is the EBP required for all residents with chronic wounds or indwelling medical devices even if they do not have an MDRO? Yes, EBP is required for all residents with chronic wounds or indwelling medical devices, regardless of whether they have an MDRO.
- Is EBP required for residents who have an MDRO but do not have chronic wounds or indwelling medical devices? Yes, residents with targeted CDC MDROs but without chronic wounds or indwelling medical devices will require the use of EBP.
- Is EBP required when a resident is under Contact Precautions? No, EBP is not required in addition to Contact Precautions. EBP is considered a practice within the guidance of the Contact Precaution protocol.
- Does a resident need to change rooms to either a private room or cohort with another ‘like’ resident when EBP is initiated? No, relocation of resident rooms is not required or advised when EBP protocol is initiated.
- Is it accurate that we will need to use EBP long-term for residents with wounds or catheters and that we cannot discontinue after a certain period? Yes, residents with MDROs and/or chronic wounds and/or indwelling devices will need EBP protocol for the duration of their stay in the facility.
- Does my therapist need to utilize EBP when treating residents in the therapy gym? Yes, Therapy team members will need to utilize EBP during treatment in the therapy gym but not during transfers from one chair to another outside the gym area.
Two questions Surveyors ask facility staff when looking at F880
How your staff responds to these two questions can either mitigate further review of infection control policies and practices, or fuel further questions and observations related to compliance with infection control guidelines and regulations.
Is your staff aware of which residents require EBP before high-contact care activities?
- How are you communicating with all staff, regardless of department, on which residents require EBP?
- Does your staff know how to apply/discard PPE to ensure compliance with EBP is met?
Is PPE readily available to staff?
- Does your staff know where supplies are kept?
- Who is responsible for stock/cleaning areas involved with EBP?
If you find yourself struggling with proper and consistent implementation of EBP requirements and staff education, schedule a mock survey with Polaris Group. Our team of Nurse Consultants will customize training and on-going education for your employees and offer real-time teaching opportunities during the mock survey. Contact us today to learn more about our healthcare solutions.
