COVID-19 and LTC July 22, 2021 - Guidance and responses were provided based on information known on 7/22/2021 and may become out of date. Guidance ...
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Guidance and responses were provided based on information known on 7/22/2021
and may become out of date. Guidance is being updated rapidly, so users should look
to CDC and NE DHHS guidance for updates.
COVID-19 and LTC
July 22, 2021
Presentation Information:
Panelists today are:
Dr. Richard Hankins richard.hankins@unmc.edu
Kate Tyner, RN, BSN, CIC ltyner@nebraskamed.com
Margaret Drake, MT(ASCP),CIC Margaret.Drake@Nebraska.gov
Lacey Pavlovsky, RN, MSN, CIC lpavlovsky@nebraskamed.com
Sarah Stream, MPH, CDA, FADAA sstream@nebraskamed.com
Rebecca Martinez, BSN, BA, RN, CIC remartinez@nebraskamed.com
Dan German dgerman@nebraskamed.com
Melody Malone, PT, CPHQ, MHA, CDP, CADDCT melody.malone@tmf.org
Debi Majo, BSN, RN Deborah.Majo@tmf.org
Moderated by Marissa Chaney Machaney@nebraskamed.com
Slides and a recording of this presentation will be available on the ICAP website:
https://icap.nebraskamed.com/covid-19-webinars/
Use the Q&A box in the webinar platform to type a question. Questions will be
read aloud by the moderator.
If your question is not answered during the webinar, please either e-mail it to NE
ICAP or call during our office hours to speak with one of our IPs.
Additional Q&A Support: In attempt to answer even more questions, ICAP Infection Preventionists and guest panelists are standing by! Some questions may be answered before the live discussion Q&A session! Please review the "Answered" tab for already-answered questions. We appreciate your understanding that all written answers provided during this webinar are based on information known on 7/22/2021 and may become out of date. Please continue to review questions for up voting.
Continuing Education Disclosures ▪1.0 Nursing Contact Hour and 1 NAB Contact Hour is awarded for the LIVE viewing of this webinar ▪In order to obtain nursing contact hours, you must be present for the entire live webinar and complete the post webinar survey ▪No conflicts of interest were identified for any member of the planning committee, presenters or panelists of the program content ▪This CE is hosted Nebraska Medicine along with Nebraska ICAP and Nebraska DHHS ▪ Nebraska Medicine is approved as a provider of nursing continuing professional development by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation
Tracking Coronavirus in Nebraska:
Latest Map and Case Count 7/22/2021
https://covid.cdc.gov/
covid-data-
tracker/#county-view
7/22/2021 7/15/2021 Tracking
Coronavirus
in Nebraska:
COVID-19
Integrated
County View
7/8/2021 7/1/2021
https://covid.cdc.gov
/covid-data-
tracker/#county-
view
COVID Hot Topics
Which Data Source Should I Be Using?
Use CMS COVID-19 Test Positivity Use the CDC COVID-19 Data
Rates for: Tracker for:
• COVID Testing (QSO-20-38-NH • Gray Zone Assessments
REVISED (cms.gov) • Risk assessments such as:
• Visitation (QSO-20-39-NH REVISED • Eye Protection
(cms.gov))
• Community Outings
• Other High-Risk Tasks
Increase County Positivity
and Visitation
Question:
The facility’s county positivity rate increased from went from 8.1 to 12.5, but the county
is still yellow. How does the affect visitation?
Go by
Color- not
positivity
rate
Facilities in a Green or Yellow County would not limit visitation
(unless in an outbreak).
Increase County Positivity and Visitation When would a facility limit visitation? Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status) with the following exceptions: • Unvaccinated residents, if the nursing home’s COVID-19 Red counties county positivity rate is >10% and
Increased Community Transmission and Eye
Protection
Community transmission rates can change regularly.
ICAP Recommends checking the CDC COVID Data Tracker at least weekly.
Eye Protection Risk Assessment Template available at
https://icap.nebraskamed.com/wp-content/uploads/sites/2/2021/05/COVID-19-
Eye-Protection-Risk-Assessment-Template.pdfEye Protection Resource
• Project Firstline Inside Infection Control Resource:
https://www.cdc.gov/infectioncontrol/projectfirstline/videos/EP10-EYE-
LowRes-New.mp4
• 6:01 video for training employees on the basics of eye protection and
COVID-19
https://www.cdc.gov/infectioncontrol/projectfirstline/resources.html?s_
cid=dhqp_001How do I get more testing
supplies?
Question:
We are an assisted living facility, and we are out of Binax cards. How
do I quickly test my symptomatic residents and staff members?
1. Increase your inventory of testing supplies (such as Binax) through
your own supply chains.
2. Check with your local health departments for testing supplies.
3. Check with other facilities in your area to see if they have extra
testing supplies (many do!).
4. PCR testing is available through NPHL.
1. Can get supplies through local health departments.Water Management –
Importance and
Requirements
Dr. Richard Hankins
Lacey Pavlovsky, RN, MSN, CIC
Rebecca Martinez, BSN, BA, RN, CICObjectives
• Describe Legionella and how Legionnaires’ disease can develop
and cause illness
• Outline why your facility needs a water management plan
• Discuss who should be included at your facility to be on the water
management team and responsible for plan development and
implementation
• List key resources for developing and implementing a water
management program
https://www.cdc.gov/legionella/downloads/toolkit.pdfWhat is Legionella &
Legionnaires’ Disease?
• Legionella is a bacteria that causes Legionnaires’ disease
• Occurs naturally in freshwater environments, like lakes and streams.
Generally, low amounts of the bacteria in freshwater do not lead to disease.
• However, Legionella can pose a health risk when it gets into building
water systems. To do this, Legionella first has to grow (increase in
numbers). Then it has to spread through small water droplets
(aerosolization) that people can breathe in. You can take steps to reduce the
risk for Legionella in your building.
• Legionnaires’ disease is a serious, and often deadly, lung infection (pneumonia)
generally caused by breathing in water droplets containing Legionella germs. It can
be caused by contaminated water accidently gets into the lungs when drinking.
https://www.cdc.gov/vitalsigns/pdf/2017-06-vitalsigns.pdf
https://www.cdc.gov/legionella/infographics/legionella-affects-
water-systems.htmlFactors that Lead to Legionella Growth
A variety of internal and external factors can lead to a Legionella problem
in your facility:
• Construction
– Ensure there are no “dead legs”. Don’t cap off at the pipe, cap
off at the main.
• Water main breaks
• Changes in municipal water quality
• Biofilm
– The slime/biofilm germs secrete is their source of food and
security.
• Scale and sediment
– Build-up uses up disinfectant and supports germ growth and
survival.
• Water temperature fluctuations
– Legionella grows best within 77°F-113°F so keep cold water
cold and keep hot water hot.
• pH fluctuations
– Disinfectants are most effective generally between 6.5 – 8.5
pH
• Inadequate levels of disinfectant
– Examples of disinfectants include chlorine, mono-chloramine,
chlorine dioxide, ultraviolet light, and ozone.
• Changes in water pressure
• Water stagnation
– Ensure water is flowing. For areas less used have a routine
flushing schedule.
– Stagnation encourages biofilm and reduces temperature and
disinfectant.
https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html
https://www.cdc.gov/legionella/downloads/toolkit.pdfLegionnaires’ disease is on the rise, reduce risk of waterborne pathogens https://www.cdc.gov/legionella/downloads/toolkit.pdf
Legionella Cases in Nebraska 2016-2020
Number of Legionella Cases by Year, Nebraska
50
45
Cases Rising
40 Until COVID-
35 19 Pandemic.
Can’t
30 conclude
pandemic
25
impact.
20
15
10
5
0
2016 2017 2018 2019 2020
Number of Cases
Public Record Request Dated July 16, 2021CMS Memo QSO-17-30- Hospitals/CAHs/NHs QSO17-30-18 (cms.gov)
CMS Regulation QSO17-30-18 (cms.gov)
Expectations:
Facilities must have water management plans and documentation that, at a minimum,
ensure each facility:
• Conducts a facility risk assessment to identify where Legionella and other
opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter,
Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could
grow and spread in the facility water system.
• Develops and implements a water management program that considers the
ASHRAE industry standard and the CDC toolkit.
• Specifies testing protocols and acceptable ranges for control measures and
document the results of testing and corrective actions taken when control limits are
not maintained.
• Maintains compliance with other applicable Federal, State and local requirements.
Note: CMS does not require water cultures for Legionella or other opportunistic water
borne pathogens. Testing protocols are at the discretion of the provider.
QSO17-30-18 (cms.gov)New CDC Toolkit Just
Image by
rawpixel.com
Published June 24, 2021
https://www.cdc.gov/legionella/downloads/toolkit.pdfEstablish a Water Management
Program Team
Consider who among your employees, partners, and outside experts can provide these skills
so that you can develop the most effective program possible.
Those who might be part of your water management program team include:
• Building owner
• Building manager/administrator
• Maintenance or engineering employees Healthcare Facilities
• Safety officers The team should also include:
• Equipment or chemical suppliers • Someone who understands accreditation
standards and licensing requirements
• Contractors/consultants
• Someone with expertise in infection prevention
(e.g., water treatment professionals)
• A clinician with expertise in infectious diseases
• Certified industrial hygienists • Risk and quality management staff
• Microbiologists
• Environmental health specialists
• State and local health officials
In some cases, you may need to train your in-house personnel or hire professionals with
specific experience in Legionella bacteria in building water systems
Legionella Toolkit-Version 1.1-June 24, 2021 (cdc.gov)Facility Risk Assessment
• Develop a basic diagram that maps all water supply sources, treatment systems,
processing steps, control measures, and end-use points (e.g., flow chart with
symbols showing skins, showers, water fountains, ice machines, etc.).
• Develop a water risk management plan based on the diagram that includes an
evaluation of the physical and chemical conditions of each step of the water flow
diagram to identify any areas where potentially hazardous conditions may occur
(these conditions can most likely occur in areas with slow or stagnant water).
CDC’s “Water Infection Control
Risk Assessment (WICRA) for
Healthcare Settings” tool is an
example for conducting a
water-related risk assessment
https://www.cdc.gov/hai/pdfs/
prevent/water-assessment-
tool-508.pdf
https://cha.com/wp-
content/uploads/2019/03/Wat
er-Management-Program-
Template.pdfDevelops and implements a
water management program
• Develop a plan for addressing the use of water in areas of buildings where water
may have been stagnant for a period. (e.g., unoccupied or temporarily closed areas)
• Evaluate the patient populations served to identify immunocompromised patients
• Develop monitoring protocols and acceptable ranges for control measures (e.g.
water temperature, residual disinfectant, pH). Additionally, protocols should include
specificity around the parameters measured, locations where measurements are
made, and appropriate corrective actions taken when parameters are out of range.
https://www.cdc.gov/vitalsign
s/pdf/2017-06-vitalsigns.pdfDocument & Take Corrective
Action
• Specifies testing protocols and acceptable ranges for control measures and
document the results of testing and corrective actions taken when control limits are
not maintained.
• The team responsible for the water management program manages the following:
• Documenting results of all monitoring activities
• Corrective actions and procedures to follow if a test result outside of
acceptable limits is obtained, including when a probable or confirmed
waterborne pathogen(s) indicates action is necessary.
• Documenting corrective actions taken when control limits are not maintained
Images by
rawpixel.com
https://www.cdc.gov/legionella/wmp/overview/growth-and-spread.html
https://www.cdc.gov/vitalsigns/pdf/2017-06-vitalsigns.pdfAnnual and Special Event
Reviews
• The individual or team responsible for the water management program reviews the
program annually and when the following occurs:
• Changes are made to the water system that would add additional risk.
• New equipment or at-risk water system(s) has been added that could
generate aerosols or be a potential source for Legionella. This includes the
commissioning of a new wing or building.
Did you shut down water
sources early on the
pandemic? Did you shut
down areas of your
facility during the
pandemic? Did you
follow re-opening
guidelines? Develop and
reviews plans as a team.
https://www.cdc.gov/vitalsigns/pdf/2017-06-vitalsigns.pdfKey Takeaways
• Legionella can cause serious illness and
death
• Your facility needs a water management
plan to keep patients and staff safe and it
is required by CMS
• A team at your facility should be
responsible for the water management
plan, not just the infection preventionist
or facilities.
• The CDC toolkit is a great starting point
and is a helpful resource.
https://www.cdc.gov/legionella/wmp/toolkit/index.htmlResources
• CMS – QSO-17-30-Hospitals/CAHs/NHs memo – Requirement to Reduce Legionella
Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of
Legionnaires’ Disease (LD)
• https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO17-30-
HospitalCAH-NH-REVISED-.pdf
• CDC – Legionella (Legionnaires’ Disease and Pontiac Fever) - Toolkit: Developing a
Water Management Program to Reduce Legionella Growth and Spread in Buildings
• https://www.cdc.gov/legionella/wmp/toolkit/index.html
• CDC – Legionella (Legionnaires’ Disease and Pontiac Fever) - Water Management
in Healthcare Facilities
• https://www.cdc.gov/legionella/wmp/healthcare-facilities/water-mgmt-
facilities.html
• CDC – Water Infection Control Risk Assessment (WICRA) for Healthcare Settings
• https://www.cdc.gov/hai/pdfs/prevent/water-assessment-tool-508.pdf
• American Society of Heating, Refrigerating and Air-Conditioning Engineers
(ASHRAE) – ASHRAE Standard 188-2018 – Legionellosis: Risk Management for
Building Water Systems
• https://www.techstreet.com/ashrae/standards/ashrae-188-
2018?gateway_code=ashrae&product_id=2020895Poll Questions
1. Are you interested in having additional, more specific
content on water management in a future webinar or
even a special webinar offering?
□ Yes – Interested
□ No – Not interested
2. How would you describe your facility’s water
management plan (WMP)? Responses are aggregated,
and are not linked to a specific facility.
□ WMP does not exist or am not sure if exists
□ WMP has been started but is minimally developed
□ WMP has been started and almost developed
□ WMP is fully developedTMF Health Quality Institute
CMS Quality Improvement
Organization
Melody Malone, PT, CPHQ, MHA
Quality Improvement SpecialistNHSN Release occurred Wednesday,
July 14, 2021
• For NHSN change details, go to:
https://tmfnetworks.org/Resources/Online-
Forums/aft/372
• Training slides are located here: LTCF COVID-19
Module Modifications – July Release pdf icon[PDF –
2 MB]
33Data Quality Alerts
• Seeing & Addressing them requires Level 3 access.
• New Document: Quick Reference Guide: Data
Quality Alerts – July 2021 pdf icon[PDF – 400 KB]
•
34NHSN Flu Module is closed for now
• And, for the 2021-2022 season they will not be
collecting data in the module.
35CMS Targeted COVID-19 Training for
Frontline Nursing Home Staff &
Management Learning
• Available through the CMS Quality,
Safety & Education Portal (QSEP). • Management staff modules:
Module 1: Hand Hygiene and PPE
• Can be completed on a cell phone
Module 2: Screening and Surveillance
• Frontline nursing home staff modules: Module 3: Cleaning the Nursing Home
Module 1: Hand Hygiene and PPE Module 4: Cohorting
Module 5: Caring for Residents with Dementia in a Pandemic
Module 2: Screening and Surveillance
Module 6: Basic Infection Control
Module 3: Cleaning the Nursing Home Module 7: Emergency Preparedness and Surge Capacity
Module 4: Cohorting Module 8: Addressing Emotional Health of Residents and Staff
Module 9: Telehealth for Nursing Homes
Module 5: Caring for Residents with
Dementia in a Pandemic Module 10: Getting Your Vaccine Delivery System Ready
• 4 hours total training time
• 3 hours total training timeCMS Targeted COVID-19 Training for Frontline Nursing Home Staff & Management Learning • We’ve asked about a report NH Leadership can access for compliance rates, and at this time there is none. • Consider having staff who are quarantined to complete the modules while at home. • Remember to build in time for new staff to do the training. 37
LTC Connect
July 22 - 1:30-2 p.m. CT
• Topic: Vaccine Hesitancy: Concerns with Fertility
and Pregnancy
• Register: LTC Connect
• Speaker: Gloria Richard-Davis, MD, MBA, NCMP,
FACOG, with the University of Arkansas Medical
Sciences (UAMS).
38Reach out to us at:
nhnetwork@tmf.org
to submit requests for
assistance with
NHSN reporting problems
or quality improvement
assistance.ICAP Updates
COVID-19 Tele-ICAR Reviews • ICAP is offering COVID-19 focused virtual ICAR reviews to LTC, outpatient and acute care facilities • The review will assess the status of COVID-19 policies and procedures and offer a summary of recommendations from ICAP • Home Health Agencies fall under the outpatient umbrella and ICAP has developed a HH focused review to support our HH partners • Contact NE ICAP at 402.552.2881 to be connected with the IP responsible for the facility
Webinar CE Process
1 Nursing Contact Hour and 1 NAB Contact Hour is offered for attending this LIVE
webinar
A separate survey must be completed for each attendee.
Nursing Contact Hours: NAB:
➢ Completion of survey is required. ➢ Completion of survey is required.
➢ The survey must be specific ➢ The survey must be specific to
to the individual obtaining the individual obtaining credit.
credit. (i.e.: 2 people cannot (i.e.: 2 people cannot be listed
be listed on the same survey) on the same survey)
➢ One certificate is issued monthly ➢ You must have a NAB membership
for all webinars attended ➢ Credit is retrieved by you
➢ Certificate comes directly from ➢ Any issues or
ICAP via email questions regarding your credit must
➢ Certificate is mailed by/on the 15th be directed to NAB customer service.
of the next month ➢ ICAP can verify survey
completion and check the roster
list
Contact Marissa with questions:
Machaney@nebraskamed.com
402-552-2881Infection Prevention and Control
Hotline Number:
Call 402-552-2881
Office Hours are Monday – Friday
8:00 AM - 4:00 PM Central Time
On-call hours are available for emergencies only
Weekends and Holidays from 8:00 AM- 4:00 PM
**Please call the main hotline number only during on-call hours**Questions and Answer
Session
Use the QA box in the webinar platform to
type a question. Questions will be read
aloud by the moderator.
Panelists:
• Dr. Richard Hankins
• Kate Tyner, RN, BSN, CIC
• Margaret Drake, MT(ASCP),CIC
• Lacey Pavlovsky, RN, MSN, CIC https://icap.nebraskamed.com/resources/
• Rebecca Martinez, BSN, BA, RN, CIC
• Sarah Stream, MPH, CDA, FADAA
• Dan German Don’t forget to Like us on Facebook
• Melody Malone, PT, CPHQ, MHA for important updates!
• Debi Majo, BSN, RN
• Moderated by Marissa Chaney
• Supported by Margaret Deacy
• Slide support from Lacey Pavlovsky,
RN, MSN, CICYou can also read
