Indiana Healthcare Associated Infection Initiative

Infection Preventionist - FT Exempt position

This position, under the direction of the infection control committee, is responsible for the effective direction,
management and operation of the infection prevention and control/epidemiology department, including education
of hospital personnel and consultation with the organization, CDC, and the county and state health departments.
The responsibilities encompass compliance with Joint Commission (JC) standards, CMS, OSHA, and state
regulations, outbreak investigation, and overall direction of the infection prevention and control program.

Responsibilities:
department in a cost-effect manner by accurately forecasting budgetary and staffing needs, and manages
expenses within budgetary constraints. Devises action plans to correct negative variances. May maintain a
competent and motivated staff through proper selection, training, evaluating and termination, as necessary.

2. Establishes, implements and administers departmental goals, objectives, policies and procedures; conducts
ongoing review of hospital policies, procedures and guidelines to identify infection control discrepancies and
implements revisions as necessary. Ensures that departmental goals are compatible with, and enhance the
hospital and organization's mission, values, and strategic plan. Provides information to hospital committees and
department managers to formulate changes in the policies, procedures and/or processes which could reduce the
spread of infection.

3. Interacts with physicians, nurses, department managers, supervisors, and occupational health and other
professional/non-professional staff members to provide resource information, resolve infection control problems,
and identify new opportunities to improve service and reduce costs.

4. Develops and enforces effectual policies and procedures for the department and hospital that ensures
compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies.

5. Directs and assists in preparing reports and statistical data for the infection control committee, medical staff
committees, medical executive committee and the facility's administration and other committees as needed.

6. Develops and coordinates the infection prevention and control program throughout the facility. Implements the
program by formulating, establishing and evaluating policies and procedures relating to patient care infection
control measures throughout the facility. Performs an annual assessment and develops action plans from the
prior year activities.

7. Makes recommendations regarding construction, renovation, environmental rounds, and assures compliance
with national and/or professional standards.

Qualifications:
MINIMUM QUALIFICATIONS

Requires a current RN license with BSN preferred, OR Masters in Public Health (MPH), OR certified medical
technologist, OR a bachelor's degree in microbiology or epidemiology.

Must have a minimum of five years clinical experience in a hospital setting or disease surveillance experience in a
public health setting.

PREFERRED QUALIFICATIONS
Association for Practitioners in Infection Control (APIC) training course or equivalent desired. Certification in
Infection Control (CIC) is preferred. Computer skills, research and basic statistical is preferred.

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department of Health
and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
 Indiana Healthcare Associated Infection Initiative

Job Title – Infection Control Practitioner

o According to the Association for Professionals in Infection Control and Epidemiology (APIC), "an
infection control practitioner (ICP) is typically a registered nurse, physician, epidemiologist, or
medical technologist who: helps to prevent healthcare-acquired infections (HAIs) by isolating
sources of infections and limiting their spread; systematically collects, analyzes and interprets health
data in order to plan, implement, evaluate and disseminate appropriate public health practices; and
trains healthcare staff through instruction and dissemination of information on infection control
practices."

Responsibilities
o The infection control practitioner plans, develops, directs, implements and evaluates infection
prevention within a hospital or health care facility. This position is supervised by the director of
nursing and serves to instruct personnel in proper infection control procedure. The infection control
practitioner investigates infection control problems and arranges follow-up care for patients exposed
to infectious diseases.

Duties
o The infection control practitioner: conducts rounds, discussing and monitoring infection control
practices with staff; collects infection data from departments, maintaining records for each case;
trains staff on implementation of infection control practices; investigates incidents of infection and
reports such incidents to the director of nursing; and ensures availability of supplies required for
infection control.

Skills
o The infection control practitioner is a highly energetic individual with the desire to develop and
implement infection control training programs. The successful candidate is one able to plan and
conduct training seminars and exercises with a working knowledge of nursing practice and theory.
The infection control practitioner possesses excellent written, interpersonal, time management and
presentation skills with flexibility to meet a wide range of service needs.

Education
o The successful candidate for infection control holds a bachelor's degree in nursing, a diploma in
hospital infection control and two to three years of experience in a hospital setting. A master's
degree in epidemiology, public health or a related field is preferred. Previous experience in teaching,
curriculum development and instruction design is also desired.

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department of Health
and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
 Indiana Healthcare Associated Infection Initiative
Infection Preventionist
Job Description and Performance Standards
Development Date: Name:
Developed by: Date:
Approved by: Reason given: New Job
Department: Quality Improvement Performance Appraisal
Reports to: Chief Executive Officer Appraisal Period:
Mission Statement
It is the mission of the hospital to provide a full range of high quality, convenient, personalized, and cost effective healthcare services to
the women and infants in our community. We strive to achieve excellence and leadership in humanistic Family-Centered Care, through
education, creative practice and research. We recognize that our most important asset is our staff and their committed and caring
attitude. Therefore it is our goal to create an atmosphere that enhances professional development, effective interaction, educational
opportunities, and promotes pride in the work place.

Basic Purpose of the Job

Leads and implements Infection Prevention/Control program. Supports the hospital quality Improvement program and structure.
Individual supports both hospital Quality Assurance (QA) and Performance Improvement activities by providing education, data
generation, and analysis of key quality indicators. Requires a variety of activities with varying degrees of complexity, high degree of
accuracy, factual dependability and independent thinking, and specialization and concentration in clinical areas.
Customers
Supervises x No supervisory responsibilities
Approx. number of direct reports
Approx. number of indirect reports

Age of Patient Populations Served x Neonates 1 – 30 days x Adults 19 – 70 yrs

Infants 30 days – 1yr x Geriatrics 70+
x Children/Adolescents 1 – 18 yrs
No Patient Contact

Contacts x Co-workers x Patients

x Volunteers x Providers (i.e., physicians)
x Visitors x Vendors
x Community agencies and advocates
Others:
x Regulatory agencies _______________

Overtime Status
Exempt x Salaried – not eligible for overtime
Hourly – eligible for
Nonexempt overtime

Job Requirements
Bachelor’s degree in nursing or related field.
Minimum Education

3-5 years nursing care experience

Minimum Work Experience

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department of
Health and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
 RN license in State of Indiana. Current CIC (Certification in Infection Control &
Required Licenses/Certifications Epidemiology) or acquire within designated time frame.
Required Skills, Knowledge, &
Abilities * Demonstrates effective interpersonal skills necessary to interact in a
professional manner with customers.
* Demonstrates leadership, creativity, and management skills.
* Language - ability to read, analyze, interpret contracts, technical procedures,
or governmental regulations. Ability to write reports and other forms of
correspondence. Ability to effectively present verbal and/or written information.
Ability to respond to the most sensitive inquiries or complaints.
* Mathematical - ability to apply mathematical concepts such as fractions,
percentages, rates and proportions to practical situations. Ability to work with
mathematical concepts such as probability and statistical tools for analysis and
problem solving. Ability to create and interpret various charts and graphs to
present in understandable format.
* Reasoning - ability to define problems, collect data, establish facts, and draw
valid conclusions. Ability to interpret instructions furnished in written, oral,
diagram, or schedule form. Ability to apply principles of logical or scientific
thinking to a wide range of intellectual and practical problems. Ability to deal
with nonverbal symbolism (formulas, scientific equations, graphs).
* Information Management and Systems - This job requires computer and
systems competency in the following areas: Enters data, retrieves data,
assembles and organizes data, uses and analyzes data. Integrates diverse
sources of data. Familiar with ISDH standards, CMS conditions of participation,
HFAP standards and medical/legal concepts in regard to healthcare data.
Knowledge and skills of applying quality improvement tools and techniques
including statistical process control.
Physical Requirements
Indicate the appropriate physical requirements of this job in the course of a shift.
Note: reasonable accommodations may be made for individuals with disabilities to perform essential functions of this position.
General Activity Number of Hours
Stand / 4-
Walk 4-8 Drive 0 Sit 8

≤ 1/3 of ≥ 1/3 of ≥ 1/3 of

Motion time time ≤ 1/3 of time time
Bend _____ x Lift x
Squat x Carry x
Crawl x Push x
Climb x Pull x
Reach _____ x

Use of Hands/Feet Gross (G) or Fine (F) Motor Skills

Right Hand G-F Right Foot G
Left Hand G-F Left Foot G

Weight Lifted/Force Exerted

Up to 10 lbs Up to 100 lbs
More than 100
Up to 25 lbs x lbs
Up to 50 lbs

Body Fluid Exposure High Risk

Low Risk x

Other Physical Requirements

Mental and Emotional Requirements
There are mental and emotional requirements of all positions working in a hospital due to the nature of the services provided. The requirements include
the ability to:
• Manage
• Handle multiple priorities anger/fear/hostility
• Manage stress
• Make decisions independently appropriately
• Works with others
• Make decisions under pressure effectively
• Works in close proximity to others and/or in a • Works alone effectively
distracting environment
Compliance and Regulatory Requirements
All employees are required to comply with all laws, regulatory guidelines, and healthcare polices. This includes, but is not limited to, the following:
• Federal, State, and Local Laws • Health Insurance Portability and Accountability Act
• State Department of Health (ISDH) (HIPAA)
▪ Accrediting Agency • Hospital Policies and Procedures
Organizational Competencies: PRIDE Standards of Performance
The following are the organizational competencies and corresponding behaviors that will be measured for all employees in the organization.
Performance Standards are found within the PRIDE Standards of Performance booklets and in the Performance Measures tool. The rating for these
competencies should be placed on the Performance Appraisal Form.
Teamwork Relationships
Facility Customer Feedback & Compliments
Courtesy & Co-Worker Commitment Creating a Spirit of Customer Service
Ownership for Hospital Communications Communication
Meetings & Events Noise Control
Family Centered Care
Respect Availability
Personal Appearance Staffing
Confidentiality & Privacy Attention to Duty
Ethics & Integrity
Accuracy Efficiency
Documentation Cost Savings Ideas
Complaints & Errors Overtime Usage
Safety Use of Resources
Quality Initiatives/Projects Productivity Measures
Community
Benefit/Service
Competence Innovation
Annual/Mandatory Testing Improvement Ideas
Certifications & Credentials Continuing Education
Rating Scale and Definitions
Performance consistently surpasses all established
standards. Activities often contribute to improved or
innovative work practices. Activities contribute to increased
Consistently Exceeds 4 unit/department results. Employees consistently complete
the work that is required, and at times go beyond
expectations.

Performance meets all established standards. Activities contribute

Consistently Meets 3 to expected unit/department results. Employees consistently
complete the work that is required.
Performance meets most, but not all, established standards.
Activities sometimes contribute to unit/department results. This
Developmental/Needs Improvement 2 category is to be used for employees who must demonstrate
improvement or more consistent performance and/or for employees
still learning their job.
Performance is consistently below requirements/expectations.
Consistently Not Performing 1
Immediate improvement is necessary.
Essential Functions
The following are essential functions which are those tasks, duties, and responsibilities that comprise the means of accomplishing the job's purpose and
objectives.
1. Facilitates the operation of the hospital Infection Prevention/Control Program and supports continuous
quality improvement
- Supports the hospital and medical staff, departments and teams including guidance, training,
technical support, celebrating successes and continued learning related to infection prevention

- Chairs the Infection Prevention/Control Committee, a sub-committee of the Family Centered Care Team
- Reports and serves as a resource member to the Family Centered Care Team

- Serves as a member and resource of Patient Safety, Product Evaluation, Peri-op, OB/GYN,
Pediatrics and the Deaconess Health System Infection Prevention & Control Committees
- Assists with compiling and submitting data for physician report cards
- Supports hospital CQI activities with data support, analysis, and internal consulting
- Monitors and maintains current knowledge of key hospital accrediting and regulatory agencies
indicators/standards.

- Develops policies and procedures that support key infection prevention and control functions

- Consults with managers in clinical and non-clinical areas.

- Identifies, investigates, reports, health care associated infections among patients and personnel
through ongoing surveillance.

- Maintains logs with infection surveillance data

- Maintains current knowledge of CDC guidelines and recommendations for infection prevention/control and
definitions of health care associated infections.
- Calculates infection rates using the CDC's recommended denominator data, prepares and
presents reports to the Family Centered Care Team.
- Responsible for providing Infection Prevention orientation and other in-service programs related to
infection prevention and control hospital-wide.
3. Collaborates with HR and provides direction regarding employee health issues such as exposures,
vaccines or vaccine preventable diseases, communicable diseases and other infection prevention/control
related issues involving hospital employees.
4. Makes recommendations regarding real or potential problems/improvement opportunities,
including desirable approaches toward resolving them.

5. Collaborates and reports to appropriate agencies / regulatory organizations

-Public Health regarding communicable diseases
-State reporting requirements and initiatives
-CDC/NHSN mandatory reporting

6. Complies with Standards of Employee Conduct as noted in Policies and Procedures.

Total Score ###

 Indiana Healthcare Associated Infection Initiative

Ambulatory Surgery Center

Infection Control Coordinator

POSITION SUMMARY:

Coordinate, integrate, and direct the center’s Infection Control Program activities, and report to the
Administrator and Clinical Nurse Manager.

SUPERVISION:

Received: Administrator/Director of Nursing

Clinical Nurse Manager
Given: All Nursing Personnel, Non-licensed Nursing Personnel, and Receptionist

QUALIFICATIONS:

1. Graduate of an accredited school of nursing required.

2. Current Indiana Licensure as a registered nurse.

3. Evidence of continuing education and training in infection control measures
4. Good command of the English language, both verbal and written.
5. Ability to work well with physicians, employees, patients, and others. Ensures the privacy and
confidentiality of patient and center information by abiding by and enforcing the HIPAA privacy &
security policies, which define each classification of employee and authorized access to patient
information.

RESPONSIBILITIES:

1. Responsible for overseeing compliance of the Exposure Control Plan and Infection Control
Practices of the facility utilizing the national standards/guidelines of the Centers for Disease
Control and Prevention (CDC), the Association for Professionals Infection Control (APIC), the
Association of Peri-Operative Registered Nurses (AORN) and the Indiana State Board of Health
(ISBH).

2. Is the primary resource person for infection control issues with ongoing collaboration with other
staff to provide optimal patient care, to evaluate their care and track infections

3. The Director of Nursing and the Infection Control Coordinator are responsible for developing
and revising policies and procedures relating to the Infection Control Program to insure infection
control standards that meet CDC, AORN, APIC, and ISBH requirements.

4. Will quarterly submit a report of infections, recommendations for action, and control measures to
the Clinical Nurse Manager, Director of Nursing/Administrator to present to the Board of
Directors.

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department
of Health and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
 5. Will meet quarterly with the Quality Assessment and Performance (QAPI) team to evaluate the
effectiveness of the surveillance plan and modify as necessary.

6. Will provide staff and patient education on risk of infection and practices to reduce risks.

7. Will report patients with communicable diseases to the appropriate county and/or state health
department.

Job description review:

I have read, understand & accept the job description for the position of Infection Control Coordinator.

Signature of Infection Control Coordinator Date of Signature

 Indiana Healthcare Associated Infection Initiative

The Role of the

INFECTION PREVENTIONIST
Long Term Care

An Infection Preventionist is an individual responsible for the Infection Prevention and Control Program,
developed to control the spread of infections and/or outbreaks.

Responsibilities include collecting, analyzing, and providing infection data and trends to nursing staff
and health care practitioners; consulting on infection risk assessment, prevention, and control
strategies; providing education and training; and implementing evidence-based infection control
practices, including those mandated by regulatory and licensing agencies, and guidelines from the
Centers for Disease Control and Prevention.

Program Development and Oversight:

Program development and oversight will emphasize the prevention and management of infections.
Program oversight involves establishing goals and priorities for the program, planning, and
implementing strategies to achieve the goals, monitoring the implementation of the program (including
the interdisciplinary team’s infection control practices), and responding to errors, problems, or other
identified issues. Additional activities involved in program development and oversight may include but
are not limited to:

• Identifying the staff’s roles and responsibilities for the routine implementation of the program
as well as in case of an outbreak of a communicable disease, an episode of infection, or the
threat of a bio-hazard attack;

• Developing and implementing appropriate infection control policies and procedures, and
training staff on them;

• Monitoring and documenting infections, including tracking and analyzing outbreaks of infection
as well as implementing and documenting actions to resolve related problems;

• Defining and managing appropriate resident health initiatives, such as:

• The immunization program (influenza, pneumonia, etc); and

• Tuberculosis screening on admission and following the discovery of a new case, and
managing active cases consistent with State requirements;

• Providing a nursing facility liaison to work with local and State health agencies; and

• Managing food safety, including employee health and hygiene, pest control, investigating
potential food-borne illnesses, and waste disposal.

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department
of Health and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
Components of the Infection Prevention and Control Program:
An effective Infection Prevention and Control Program incorporates, but is not limited to, the following
components:

• Policies, procedures, and practices which promote consistent adherence to evidence-based

infection control practices;

• Program oversight including planning, organizing, implementing, operating, monitoring, and

maintaining all of the elements of the program and ensuring that the facility’s interdisciplinary
team is involved in infection prevention and control;

• Surveillance, including process and outcome surveillance, monitoring, data analysis,

documentation and communicable diseases reporting (as required by State and Federal law
and regulation);

• Education, including training in infection prevention and control practices, to ensure

compliance with facility requirements as well as State and Federal regulation; and

• Antibiotic review including reviewing data to monitor the appropriate use of antibiotics in the
resident population.

Activities related to the Infection Prevention and Control Program may include but are not limited to:

• Undertaking process and/or outcome surveillance activities to identify infections that are
causing, or have the potential to cause an outbreak;

• Conducting data analysis to help detect unusual or unexpected outcomes and to determine
the effectiveness of infection prevention and control practices;

• Documenting observations related to the causes of infection and/or infection trends; and

• Implementing measures to prevent the transmission of infectious agents and to reduce risks
for device and procedure-related infections.

Policies and Procedures:

Facility policies and procedures governing Infection Prevention and Control shall be reviewed
periodically and revised as needed to conform to current standards of practice or to address specific
facility concerns.

Surveillance:
Two types of surveillance (process and outcome) shall be implemented.

Process Surveillance
Process surveillance reviews practices directly related to resident care in order to identify whether the
practices comply with established prevention and control procedures and policies based on recognized
guidelines. Examples of this type of surveillance include monitoring of compliance with transmission
based precautions, proper hand hygiene, and the use and disposal of gloves. Process surveillance
determines, for example, whether the facility:

• Minimizes exposure to a potential source of infection;

Information excerpted from the SOM, Appendix PP, Interpretive Guidance, F441
(Rev. 55, Issued: 12-02-09; Effective/Implementation Date: 09-30-09)
 • Uses appropriate hand hygiene prior to and after all procedures;

• Ensures that appropriate sterile techniques are followed; for example, that staff:

• Uses sterile gloves, fluids, and materials, when indicated, depending on the site and the
procedure;

• Avoids contaminating sterile procedures; and

• Ensures that contaminated/non-sterile items are not placed in a sterile field.

• Uses Personal Protective Equipment (PPE) when indicated;

• Ensures that reusable equipment is appropriately cleaned, disinfected, or reprocessed; and

• Uses single-use medication vials and other single use items appropriately (proper disposal
after every single use).

Outcome Surveillance
In contrast to process surveillance, outcome surveillance is designed to identify and report evidence of
an infection. The outcome surveillance process consists of collecting/documenting data on individual
cases and comparing the collected data to standard written definitions (criteria) of infections. The IP will
review data (including residents with fever or purulent drainage, and cultures or other diagnostic test
results consistent with potential infections) to detect clusters and trends. Other sources of relevant data
may include antibiotic orders, medication regimen review reports, and medical record documentation
such as physician progress notes and transfer summaries accompanying newly admitted residents.

Documentation:
The Infection Prevention and Control Program will define how often and by what means surveillance
data will be collected, regardless of whether the facility creates its own forms, purchases preprinted
forms, or uses automated systems.

Monitoring:
Monitoring of the implementation of the program, its effectiveness, the condition of any resident with an
infection, and the resolution of the infection and/or an outbreak is an integral part of nursing facility
infection surveillance.

Data Analysis:
Determining the origin of infections helps the facility identify the number of residents who developed
infections within the nursing facility. Comparing current infection control surveillance data (including the
incidence or prevalence of infections and staff practices) to past data enables detection of unusual or
unexpected outcomes, trends, effective practices, and performance issues. The facility can then
evaluate whether it needs to change processes or practices to enhance infection prevention and
minimize the potential for transmission of infections.
Surveillance reports should be shared with appropriate individuals including, but not limited to, the
director of nursing and medical director. In addition, it is important that the staff and practitioners
receive reports that are relevant to their practices to help them recognize the impact of their care on
infection rates and outcome.

Information excerpted from the SOM, Appendix PP, Interpretive Guidance, F441
(Rev. 55, Issued: 12-02-09; Effective/Implementation Date: 09-30-09)
Communicable Disease Reporting:
The facility shall have a process that enables it to consistently comply with State and local health
department requirements for reporting communicable diseases.

Education:
Both initial and ongoing infection control education shall be provided to assist staff to comply with
infection control practices. Updated education and training are appropriate when policies and
procedures are revised or when there is a special circumstance, such as an outbreak, that requires
modification or replacement of current practices. In addition to education regarding general infection
control principles, some infection control training is discipline and task specific (e.g., insertion of urinary
catheters, suctioning, intravenous care or blood glucose monitoring).

Essential topics of infection control training will include, but not be limited to routes of disease
transmission, hand hygiene, sanitation procedures, MDROs, transmission-based precaution
techniques, and the federally required OSHA education.

Antibiotic Review:
Because of increases in MDROs, review of the use of antibiotics (including comparing prescribed
antibiotics with available susceptibility reports) is a vital aspect of the Infection Prevention and Control
Program. It is the physician’s (or other appropriate authorized practitioner’s) responsibility to prescribe
appropriate antibiotics and to establish the indication for use of specific medications. As part of the
medication regimen review, the consultant pharmacist can assist with the oversight by identifying
antibiotics prescribed for resistant organisms or for situations with questionable indications, and
reporting such findings to the director of nursing and the attending physician.

Outbreaks:
It is important that facilities know how to recognize and contain infectious outbreaks. An outbreak is
typically one or more of the following:
One case of an infection that is highly communicable;
Trends that are 10 percent higher than the historical rate of infection for the facility that may
reflect an outbreak or seasonal variation and therefore warrant further investigation; or
Occurrence of three or more cases of the same infection over a specified length of time on the
same unit or other defined areas.

Once an outbreak has been identified, it is important that the facility take the appropriate steps to
contain it and report the outbreak to the Indiana State Department of Health as dictated in the Unusual
Occurrence Guidance.

Information excerpted from the SOM, Appendix PP, Interpretive Guidance, F441
(Rev. 55, Issued: 12-02-09; Effective/Implementation Date: 09-30-09)
 Indiana Healthcare Associated Infection Initiative

Employee Introduction to Elements of Infection Prevention and Control

Long Term Care

As an employee of this facility, I acknowledge the following:

This facility maintains an infection control program designed to provide a safe, sanitary, and
comfortable environment and to help prevent the development and transmission of diseases and
infection.

This facility has established an infection control program under which it:

(1) Investigates, controls, and prevents infections in the facility, including, but not limited to, a
surveillance system to:
(A) monitor, investigate, document, and analyze the occurrence of nosocomial infection;
(B) recommend corrective action; and
(C) review findings at least quarterly.

This system enables the facility to analyze clusters and/or significant increases in the rate of infection.

This system decides what procedures (such as isolation) should be applied to an individual resident to
prevent the spread of infection that isolates the infectious agent and includes full implementation of
standard precautions.
 I understand that, as a caregiver, I must adhere to any isolation procedures indicated for an
individual resident.
 I understand that should I have a communicable disease or infected and/or draining skin lesion, I
am prohibited from direct contact with residents or their food (if direct contact will transmit the
disease) until the condition is resolved.
 I understand that any persons with suspected or proven active tuberculosis will not be permitted to
work until determined to be noninfectious and documentation is provided for the employee record.
 I understand that I am required to wash my hands after each direct resident contact for which hand
washing is indicated by accepted professional practice.
 I understand my responsibility to perform necessary hand hygiene.

Recommended techniques for washing hands with soap and water include wetting hands first with
clean, running warm water, applying the amount of product recommended by the manufacturer to
hands, and rubbing hands together vigorously for at least 15 seconds covering all surfaces of the hands
and fingers; then rinsing hands with water and drying thoroughly with a disposable towel; and turning
off the faucet on the hand sink with the disposable paper towel.

Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR
are also appropriate for cleaning hands and can be used for direct resident care. Recommended
techniques for performing hand hygiene with an ABHR include applying product to the palm of one
hand and rubbing hands together, covering all surfaces of hands and fingers, until the hands are dry. In
addition, gloves or the use of baby wipes are not a substitute for hand hygiene.

The Indiana Healthcare Associated Infection Initiative is a health care quality initiative of the Indiana State Department
of Health and the University of Indianapolis Center for Aging & Community. 2011. Version: Apr 12, 2011
The following is a list of some situations that require hand hygiene:

• When coming on duty;

• When hands are visibly soiled (hand washing with soap and water);Before and after direct resident
contact (for which hand hygiene is indicated by acceptable professional practice);

• Before and after performing any invasive procedure (e.g., fingerstick blood sampling);

• Before and after entering isolation precaution settings;

• Before and after eating or handling food (hand washing with soap and water);

• Before and after assisting a resident with meals;

• Before and after assisting a resident with personal care (e.g., oral care, bathing);

• Before and after handling peripheral vascular catheters and other invasive devices;

• Before and after inserting indwelling catheters;

• Before and after changing a dressing;

• Upon and after coming in contact with a resident’s intact skin, (e.g., when taking a pulse or blood
pressure, and lifting a resident);

• After personal use of the toilet (hand washing with soap and water);

• Before and after assisting a resident with toileting;

• After contact with a resident with infectious diarrhea including, but not limited to infections caused by
norovirus, salmonella, shigella, and C. difficile (hand washing with soap and water);

• After blowing or wiping nose;

• After contact with a resident’s mucous membranes and body fluids or excretions;

• After handling soiled or used linens, dressings, bedpans, catheters and urinals;

• After handling soiled equipment or utensils;

• After performing your personal hygiene (hand washing with soap and water);

• After removing gloves or aprons; and

• After completing duty.

Information excerpted from the SOM, Appendix PP, Interpretive Guidance, F441
(Rev. 55, Issued: 12-02-09; Effective/Implementation Date: 09-30-09);
and 410 IAC 16.2-3.1-18
 I understand that Standard precautions are based upon the principle that all blood, body fluids,
secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain
transmissible infectious agents.

 I understand that Standard precautions are intended to be applied to the care of all persons in all
healthcare settings, regardless of the suspected or confirmed presence of an infectious agent.

Standard precautions include but are not limited to hand hygiene, safe injection practices, the proper
use of PPE (e.g., gloves, gowns, and masks), resident placement, and care of the environment,
textiles, and laundry. Also, equipment or items in the resident environment likely to have been
contaminated with infectious fluids or other potentially infectious matter must be handled in a manner
so as to prevent transmission of infectious agents, (e.g., wear gloves for handling soiled equipment,
and properly clean and disinfect or sterilize reusable equipment before use on another resident). In
addition to proper hand hygiene, it is important for staff to use appropriate protective equipment as a
barrier to exposure to any body fluids (whether known to be infected or not). For example, in situations
identified as appropriate, gloves and other equipment such as gowns and masks are to be used as
necessary to control the spread of infections. Standard precautions are also intended to protect
residents by ensuring that healthcare personnel do not carry infectious agents to residents on their
hands or via equipment used during resident care.

 I understand that I must handle, store, process and transport linens so as to prevent the spread of
infection.

_________________________________ ______________________
Employee Signature Date

_________________________________ ______________________
Supervisor Signature Date

Information excerpted from the SOM, Appendix PP, Interpretive Guidance, F441
(Rev. 55, Issued: 12-02-09; Effective/Implementation Date: 09-30-09);
and 410 IAC 16.2-3.1-18