INFECTION CONTROL ASSESSMENT AND RESPONSE USER …

INFECTION CONTROL

ASSESSMENT AND RESPONSE USER GUIDE

HTTPS://ICAR-HAI.ORG

Prepared by the Carolina Center for Health Informatics in the Department of

Emergency Medicine, University of North Carolina at Chapel Hill

Version 2.0

March 6, 2017

Questions? Contact us at [email protected]

mailto:[email protected]

ICAR HAI User Guide

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Table of Contents Login .................................................................................................................................................................................................................. 3

User Profile ........................................................................................................................................................................................................ 7

My Facility List ................................................................................................................................................................................................ 15

Assessments ..................................................................................................................................................................................................... 17

Acute Care Hospital Assessment Questions ............................................................................................................................................... 20

Dialysis Assessment Questions ................................................................................................................................................................... 42

LTCF Assessment Questions ....................................................................................................................................................................... 59

Outpatient Assessment Questions.............................................................................................................................................................. 68

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Login To begin the assessment process, please go to https://icar-hai.org and click on login.

All users need an NCID to complete an assessment. NCID is the standard identity management and access service provided to state,

local, business, and individual users. Please go to https://ncidp.nc.gov/ncidsspr/ to register for an NCID if you do not already have one.

Please select to register as a business user.

The NCID will be activated and ready for use immediately.

Figure 1: ICAR HAI Homepage

https://icar-hai.org/

https://ncidp.nc.gov/ncidsspr/

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Figure 2: NCID New User Registration

Register for your NCID as a Business

User.

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Once you have your NCID, use the login button to login. The login button on https://icar-hai.org will redirect you to

the NCID login page.

Figure 3: Login Button on ICAR HAI Home Page

https://icar-hai.org/

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Figure 4: NCID Login Page

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User Profile The first time users successfully log in to ICAR HAI, they will be asked to complete a User Profile. Some of the

information will already be populated from the NCID login, but additional information is required. Once all

information has been entered, click the Next button to continue.

Figure 5: User Profile

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After clicking the Next button, first-time users are provided an instructional overview of the process for completing the assessments.

1. The first step is to register the facility(ies) users want to assess by entering the NPI for that facility. If users do not know the NPI

for a facility, they can use the CMS-provided NPI search feature available at https://npiregistry.cms.hhs.gov/ .

2. After users validate the NPI information, they can submit the information to add it to their Facility List.

a. Users should provide a secure fax number for their facility, but a placeholder can be provided until the secure fax can be

determined (enter an unknown number as 111-111-1111).

3. NC Division of Public Health will activate facility registrations so that users can complete the infection control assessment. Users

will be notified by email when the assessment is available. The Facility List page will show the status of all assessments.

4. When users click on the NEXT button, they are directed to the Register Facility page.

https://npiregistry.cms.hhs.gov/

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Figure 6: First-time User Instructions

Use these links to

Access all reports available to you

View the User Guide

Update your user Profile

Logout

ICAR HAI User Guide

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The first step is to register the facility(ies) users want to assess by entering the NPI for that facility. If users do not know the NPI for a

facility, they can use the CMS-provided NPI search feature available at https://npiregistry.cms.hhs.gov/ .

Figure 7: NPI Search

https://npiregistry.cms.hhs.gov/

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The user has the opportunity to review the information stored for the NPI entered by that user.

If all information is correct, the user can simply click on the Register Facility button. If the information is incorrect, the user can make

edits and then click on the Register Facility button. If the incorrect NPI was entered by the user, he/she can click on the Cancel button

to enter a different NPI.

If the NPI for a user’s facility is not found in the system, the user should contact the help desk at

[email protected] for more information. The Help Desk can add the facility to the system.

Users are required to provide a secure fax number for their facility. If the secure fax number is not known at the time of facility

registration, the user should enter all “1”s, e.g., “1111111111.” The user can update the secure fax number at any time by clicking on the

facility name on the My Facilities and Assessments Reports Page.

NOTE: The hospital names used in this User Guide are for explanatory purposes only and do not reflect real assessments.

mailto:[email protected]

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Figure 8: Register Facility - Acute Care Hospital Example

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For Long Term Care Facilities (LTCF), there are three additional questions. The users are asked if the LTCF is affiliated with a

hospital/hospital system and, if so, to provide additional information.

Figure 9: Register Facility - Long Term Care Facility Example

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Figure 10: Facility Registration Confirmation - Long Term Care Facility Example

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My Facility List Once facilities are registered, users can view them on the Facility List page. The facility will have a status of “Requested, Pending.” The

Facility List page can be accessed from the Facility Registration Confirmation Page or from the Reports page. On the Reports Page,

select “My Facilities and Assessments.”

Figure 11: Reports Page Showing My Facilities and Assessments Report

After the NC Division of Public Health has activated an assessment for a facility registered by a user, that user will receive an email

notification that the assessment is available for completion. At activation, the Assessment Status will be changed to “Ready to Begin”

and will be hyperlinked to the assessment page. The sample screenshot below shows facilities with different Assessment Status types.

The user can click on the link in Assessment Status to complete the assessment at any time during an active assessment time period.

Users can update the address, phone and secure fax information for a facility by clicking on the Facility Name.

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Figure 12: Sample Facility List showing the different Assessment Status Types

Click on hyperlinks to begin assessments. Click on the facility name to update address,

telephone, etc. for that facility

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Assessments The Assessments are organized into sections or “tabs.” Each section covers a different infection control component.

Required questions are marked with a red asterisk (*). These questions must be answered for a section to be considered

complete.

Please complete the assessment based on practices and policies that are currently practiced routinely. Please do not include

practices that are currently implemented on a pilot or trial basis in your responses.

Click the SAVE button at the bottom of the page to save any data entered before moving to another tab.

Remember to save your data entry regularly even if you are staying on the same tab/section. Your session will

timeout after 30 minutes without saving your responses.

The Status section will provide a summary of your assessment progress.

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Figure 13: Sample Screenshot from Acute Care Hospital Assessment

Red asterisks * mark required questions.

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Users must click on the Save button at the bottom of each section to save their answers before proceeding to another section. Users

must also save at least once every 30 minutes to avoid data loss resulting from a session time-out.

Figure 14: SAVE Button

Please save any data entry before clicking on another tab. A warning message will appear if users do not save their data entry before

clicking on another tab.

Figure 15: Warning Message if a User Clicks on Another Section without Saving Current Section

ICAR HAI User Guide

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The remaining pages of this User Guide list the questions for each facility type: Acute Care Hospitals, Dialysis, Long Term Care

Facilities and Outpatient settings.

Acute Care Hospital Assessment Questions

The questions asked for Acute Care Hospitals are included in the table below. The questions are organized by section to correspond with

the Web interface.

Table 1: Acute Care Hospital Assessment Questions

Hospital

Assessment

Section

Question # Question Possible Answers (if applicable)

Facility Information 1 Rationale for Assessment (Select all that apply): Outbreak | Participation in

Infection Control and Response

(ICAR) | Recommendation of

accrediting organization or state

survey agency | Increase in

healthcare-associated infections in

the past 12 months | Participation

in prevention collaborative |

NHSN Data | Other

(If other, please specify)

Facility Information 2 If you selected "Increase in healthcare-associated infections" above,

please select infection types that have increased. (Select all that

apply):

CAUTI | CLABSI | SSI | CDI |

VAE | MDRO | Other


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Hospital

Assessment

Section


Facility Information 3 Facility type: Acute Care Hospital | Critical

Access Hospital | Long-term

Acute Care Hospital (LTACH) |

Other


Facility Information 4 Number of Licensed Beds

Facility Information 5 Number of Infection Preventionist Full-Time Equivalents

Infrastructure 1 Hospital provides fiscal and human resources support for

maintaining the infection prevention and control program.

Yes | No

Infrastructure 2 The person(s) charged with directing the infection prevention and

control program at the hospital is/are qualified and trained in

infection control.

Yes | No

Infrastructure 2a The person responsible for the Infection Prevention program has

successfully completed the certification exam developed by the

Certification Board for Infection Control & Epidemiology (CIC)

Yes | No

Infrastructure 2b The person responsible for the Infection Prevention program

participates in infection control courses organized by recognized

professional societies or universities (e.g., APIC, SHEA, SPICE)

Yes | No

Infrastructure 3 Infection prevention and control program performs an annual

facility infection risk assessment that evaluates and prioritizes

potential risks for infections, contamination, and exposures and the

program’s preparedness to eliminate or mitigate such risks.

Yes | No

Infrastructure 4 Written infection control policies and procedures are available,

current, and based on evidence-based guidelines (e.g.,

CDC/HICPAC), regulations, or standards.

Yes | No

Infrastructure 5 Infection prevention and control program provides infection

prevention education to patients, family members, and other

caregivers.

Yes | No

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Hospital

Assessment

Section


Hand Hygiene 1 Hospital has a competency-based training program for hand

hygiene.

Yes | No

Hand Hygiene 1a Training is provided to all healthcare personnel, including all

ancillary personnel not directly involved in patient care but

potentially exposed to infectious agents (e.g., food tray handlers,

housekeeping, volunteer personnel).

Yes | No

Hand Hygiene 1b Training is provided upon hire, prior to provision of care at this

hospital.

Yes | No

Hand Hygiene 1c Training is provided at least annually. Yes | No

Hand Hygiene 1d Personnel are required to demonstrate competency with hand

hygiene following each training.

Yes | No

Hand Hygiene 1e Hospital maintains current documentation of hand hygiene

competency for all personnel.

Yes | No

Hand Hygiene 2 Hospital regularly audits (monitors and documents) adherence to

hand hygiene.

Yes | No

Hand Hygiene 3 Hospital provides feedback from audits to personnel regarding their

hand hygiene performance.

Yes | No

Hand Hygiene 4 Supplies necessary for adherence to hand hygiene (e.g., soap, water,

paper towels, alcohol-based hand rub) are readily accessible in

patient care areas.

Yes | No

Hand Hygiene 5 Hand hygiene policies promote preferential use of alcohol-based

hand rub over soap and water except when hands are visibly soiled

(e.g., blood, body fluids) or after caring for a patient with known or

suspected C. difficile or norovirus.

Yes | No

PPE 1 Hospital has a competency-based training program for personal

protective equipment (PPE).

Yes | No

PPE 1a Training is provided to all personnel who use PPE. Yes | No

PPE 1b Training is provided upon hire, prior to provision of care at this

hospital.

Yes | No

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Hospital

Assessment

Section


PPE 1c Training is provided at least annually. Yes | No

PPE 1d Training is provided when new equipment or protocols are

introduced.

Yes | No

PPE 1e Training includes 1) appropriate indications for specific PPE

components, 2) proper donning, doffing, adjustment, and wear of

PPE, and 3) proper care, maintenance, useful life, and disposal of

PPE.

Yes | No

PPE 1f Personnel are required to demonstrate competency with selection

and use of PPE (i.e., correct technique is observed by trainer)

following each training.

Yes | No

PPE 1g Hospital maintains current documentation of PPE competency for

all personnel who use PPE.

Yes | No

PPE 2 Hospital regularly audits (monitors and documents) adherence to

proper PPE selection and use, including donning and doffing.

Yes | No

PPE 3 Hospital provides feedback to personnel regarding their

performance with selection and use of PPE.

Yes | No

PPE 4 Supplies necessary for adherence to personal protective equipment

recommendations specified under Standard and Transmission-based

Precautions (e.g., gloves, gowns, mouth, eye, nose, and face

protection) are available and located near point of use.

Yes | No

PPE 5 The hospital’s respiratory protection program provides annual

respiratory fit testing for all personnel who are anticipated to

require respiratory protection.

Yes | No

PPE 5a Hospital maintains supplies of respiratory protection devices (e.g.,

Powered air purifying respirator) to be used by personnel who

cannot be fitted.

Yes | No

PPE 5b Healthcare personnel are educated about factors that may

compromise proper fit and function of respiratory protection

devices (e.g., weight gain/loss, facial hair).

Yes | No

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Hospital

Assessment

Section


CAUTI 1 Hospital has physician and/or nurse champions for CAUTI

prevention activities.

Yes | No

CAUTI 2 Hospital has a competency-based training program for insertion of

urinary catheters.

Yes | No

CAUTI 2a Training is provided to all personnel who are given responsibility

for insertion of urinary catheters. Personnel may include, but are

not limited to, nurses, nursing assistants, medical assistants,

technicians, and physicians.

Yes | No

CAUTI 2b Training is provided upon hire, prior to being allowed to perform

urinary catheter insertion.

Yes | No

CAUTI 2c Training is provided at least annually. Yes | No

CAUTI 2d Training is provided when new equipment or protocols are

introduced.

Yes | No

CAUTI 2e Personnel are required to demonstrate competency with insertion

(i.e., correct technique is observed by trainer) following each

training.

Yes | No

CAUTI 2f Hospital maintains current documentation of competency with

urinary catheter insertion for all personnel who insert urinary

catheters.

Yes | No

CAUTI 3 Hospital regularly audits (monitors and documents) adherence to

recommended practices for insertion of urinary catheters.

Yes | No

CAUTI 4 Hospital provides feedback from audits to personnel regarding their

performance for insertion of urinary catheters.

Yes | No

CAUTI 5 Hospital has a competency-based training program for maintenance

of urinary catheters.

Yes | No

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Hospital

Assessment

Section


CAUTI 5a Training is provided to all personnel who are given responsibility

for urinary catheter maintenance (e.g., perineal care, emptying the

drainage bag aseptically, maintaining the closed drainage system,

maintaining unobstructed urine flow). Personnel may include, but

are not limited to, nurses, nursing assistants, medical assistants,

technicians, and transport personnel.

Yes | No

CAUTI 5b Training is provided upon hire, prior to being allowed to perform

urinary catheter maintenance.

Yes | No

CAUTI 5c Training is provided at least annually. Yes | No

CAUTI 5d Training is provided when new equipment or protocols are

introduced.

Yes | No

CAUTI 5e Personnel are required to demonstrate competency with catheter

maintenance (i.e., correct technique is observed by trainer)


Yes | No

CAUTI 5f Hospital maintains current documentation of competency with

urinary catheter maintenance for all personnel who maintain urinary

catheters.

Yes | No

CAUTI 6 Hospital regularly audits (monitors and documents) adherence to

recommended practices for maintenance of urinary catheters.

Yes | No

CAUTI 7 Hospital provides feedback from audits to personnel regarding their

performance for maintenance of urinary catheters.

Yes | No

CAUTI 8 Patients with urinary catheters are assessed, at least daily, for

continued need for the catheter.

Yes | No

CAUTI 8a Hospital routinely audits adherence to daily assessment of urinary

catheter need.

Yes | No

CLABSI 1 Hospital has physician and/or nurse champions for CLABSI

prevention activities.

Yes | No

CLABSI 2 Hospital has a competency-based training program for insertion of

central venous catheters.

Yes | No

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Hospital

Assessment

Section


CLABSI 2a Training is provided to all personnel who are given responsibility

for insertion of central venous catheters. Personnel may include, but

are not limited to, physicians, physician assistants, and members of

line insertion teams.

Yes | No

CLABSI 2b Training is provided upon hire, prior to being allowed to perform

central venous catheter insertion.

Yes | No

CLABSI 2c Training is provided at least annually. Yes | No

CLABSI 2d Training is provided when new equipment or protocols are

introduced.

Yes | No

CLABSI 2e Personnel are required to demonstrate competency with insertion

(i.e., correct technique is observed by trainer) following each

training.

Yes | No

CLABSI 2f Hospital maintains current documentation of competency with

central venous catheter insertion for all personnel who insert central

venous catheters.

Yes | No

CLABSI 3 Hospital regularly audits (monitors and documents) adherence to

recommended practices for insertion of central venous catheters.

Yes | No

CLABSI 4 Hospital provides feedback from audits to personnel regarding their

performance for insertion of central venous catheters.

Yes | No

CLABSI 5 Hospital has a competency-based training program for maintenance

of central venous catheters.

Yes | No

CLABSI 5a Training is provided to all personnel who maintain central venous

catheters (e.g., scrub the hub, accessing the catheter, dressing

changes). Personnel may include, but are not limited to, nurses,

nursing assistants, physicians, and physician assistants.

Yes | No

CLABSI 5b Training is provided upon hire, prior to being allowed to perform

central venous catheter maintenance.

Yes | No

CLABSI 5c Training is provided at least annually. Yes | No

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Hospital

Assessment

Section


CLABSI 5d Training is provided when new equipment or protocols are

introduced.

Yes | No

CLABSI 5e Personnel are required to demonstrate competency with

maintenance (i.e., correct technique is observed by trainer)

following each training

Yes | No

CLABSI 5f Hospital maintains current documentation of competency with

central venous catheter maintenance for all personnel who maintain

central venous catheters.

Yes | No

CLABSI 6 Hospital regularly audits (monitors and documents) adherence to

recommended practices for maintenance of central venous

catheters.

Yes | No

CLABSI 7 Hospital provides feedback from audits to personnel regarding their

performance for maintenance of central venous catheters.

Yes | No

CLABSI 8 Patients with central venous catheters are assessed, at least daily,

for continued need for the catheter.

Yes | No

CLABSI 8a Hospital routinely audits adherence to daily assessment of central

venous catheter need.

Yes | No

VAE N/A Does your facility provide care to ventilated patients?

(If answer is no, VAE section is considered complete)

Yes | No

VAE 1 Hospital has physician and/or nurse champions for VAE prevention

activities.

Yes | No

VAE 2 Hospital has a competency-based training program addressing

prevention of VAEs.

Yes | No

VAE 2a Training is provided to all personnel who provide respiratory

therapy for ventilated patients (e.g., suctioning, administration of

aerosolized medications). Personnel may include, but are not

limited to, respiratory therapists and nurses.

Yes | No

VAE 2b Training is provided upon hire, prior to being allowed to provide

respiratory therapy for ventilated patients.

Yes | No

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Hospital

Assessment

Section


VAE 2c Training is provided at least annually. Yes | No

VAE 2d Training is provided when new equipment or protocols are

introduced.

Yes | No

VAE 2e Personnel are required to demonstrate competency with respiratory

therapy practices (i.e., correct technique is observed by trainer)


Yes | No

VAE 2f Hospital maintains current documentation of competency with

respiratory practices for all personnel who provide respiratory

therapy for ventilated patients.

Yes | No

VAE 3 Hospital regularly audits (monitors and documents) adherence to

recommended practices for management of ventilated patients (e.g.,

suctioning, administration of aerosolized medications).

Yes | No

VAE 4 Hospital provides feedback from audits to personnel regarding their

performance for management of ventilated patients.

Yes | No

VAE 5 Patients requiring invasive ventilation are assessed, at least daily,

for continued ventilator need.

Yes | No

VAE 5a Hospital routinely audits adherence to daily assessment of

ventilator need.

Yes | No

VAE 6 Hospital has a program that includes daily spontaneous breathing

trials and lightening of sedation in eligible patients.

Yes | No

VAE 7 Hospital has an oral hygiene program for ventilated patients. Yes | No

Injection Safety 1 Hospital has a competency-based training program for preparation

and administration of parenteral medications (e.g., SQ, IM, IV)

outside of the pharmacy.

Yes | No

Injection Safety 1a Training is provided to all personnel who prepare and/or administer

injections and parenteral infusions.

Yes | No

Injection Safety 1b Training is provided upon hire, prior to being allowed to prepare

and/or administer injections and parenteral infusions.

Yes | No

Injection Safety 1c Training is provided at least annually. Yes | No

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Hospital

Assessment

Section


Injection Safety 1d Training is provided when new equipment or protocols are

introduced.

Yes | No

Injection Safety 1e Personnel are required to demonstrate competency with preparation

and/or administration of injections and parenteral infusions


Yes | No

Injection Safety 1f Hospital maintains current documentation of competency with

preparation and/or administration procedures for all personnel who

prepare and/or administer injections and parenteral infusions.

Yes | No

Injection Safety 2 Hospital regularly audits (monitors and documents) adherence to

safe infection practices.

Yes | No

Injection Safety 3 Hospital provides feedback from audits to personnel regarding their

adherence to safe injection practices.

Yes | No

Injection Safety 4 Hospital has a drug diversion prevention program that includes

consultation with the IP program to assess patient safety risks when

drug tampering (involving alteration or substitution) is suspected or

identified.

Yes | No

Injection Safety 4a Hospital has a written protocol or plan to describe how the hospital

would assess risk to patients if tampering is suspected or identified.

Yes | No

Injection Safety 4b Protocol/plan includes notification of public health / health

department to assist with risk assessment for disease transmission.

Yes | No | Not Applicable

SSI N/A Does your facility perform surgical procedures?

(If answer is no, SSI section is considered complete)

Yes | No

SSI 1 Hospital has a surgical care improvement program. Yes | No

SSI N/A The surgical care improvement program addresses appropriate

prophylactic antibiotic use including the following:

N/A

SSI 1a Preoperative timing of prophylactic antibiotic administration

(within 1 hour prior to incision or 2 hours for vancomycin or

fluoroquinolones).

Yes | No

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Hospital

Assessment

Section


SSI 1b Appropriate prophylactic antibiotic selection based on procedure

type.

Yes | No

SSI 1c Discontinuation of prophylactic antibiotics within 24 hours (48

hours for CABG or other cardiac surgery) after surgical end time.

Yes | No

SSI 1d The surgical care improvement program addresses prompt removal

of urinary catheter on post-op day 1 or 2, unless there is a

documented appropriate reason for continued use.

Yes | No

SSI 2 Hospital regularly audits (monitors and documents) adherence to

elements of surgical care improvement program.

Yes | No

SSI 3 Hospital provides feedback from audits to personnel regarding their

adherence to elements of the surgical care improvement program.

Yes | No

SSI 4 Hospital regularly audits (monitors and documents) adherence to

recommended infection control practices for SSI prevention.

Yes | No

SSI N/A Auditing includes the following: N/A

SSI 4a Adherence to preoperative surgical scrub and hand hygiene. Yes | No

SSI 4b Appropriate use of surgical attire and drapes. Yes | No

SSI 4c Adherence to aseptic technique and sterile field. Yes | No

SSI 4d Proper ventilation requirements in surgical suites. Yes | No

SSI 4e Minimization of traffic in the operating room. Yes | No

SSI 4f Adherence to cleaning and disinfection of environmental surfaces. Yes | No

SSI 5 Hospital provides feedback from audits to personnel regarding their

adherence to surgical infection control practices.

Yes | No

CDI 1 Hospital has physician and/or nurse champions for CDI prevention

activities.

Yes | No

CDI 2 Hospital regularly audits (monitors and documents) adherence to

recommended infection control practices for CDI prevention.

Yes | No

CDI N/A Auditing includes the following: N/A

CDI 2a Adherence to hand hygiene. Yes | No

CDI 2b Appropriate use of PPE. Yes | No

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Hospital

Assessment

Section


CDI 2c Compliance with Contact Precautions, including use of dedicated or

disposable equipment.

Yes | No

CDI 2d Adherence to cleaning and disinfection procedures, including use of

sporicidal disinfectants if part of hospital policy.

Yes | No

CDI 3 Hospital provides feedback from audits to personnel regarding their

adherence to recommended infection control practices for CDI

prevention.

Yes | No

CDI 4 Hospital has specific antibiotic stewardship strategies in place to

reduce CDI.

Yes | No

CDI N/A Strategies include the following: N/A

CDI 4a Hospital has strategies to reduce unnecessary use of antibiotics that

are high risk for CDI (e.g., fluoroquinolones, 3rd/4th generation

cephalosporins).

Yes | No

CDI 4b Hospital reviews appropriateness of antibiotics prescribed for

treatment of other conditions (e.g., urinary tract infection) for

patients with new or recent CDI diagnosis.

Yes | No

CDI 4c Hospital educates providers about the risk of CDI with antibiotics. Yes | No

CDI 4d Hospital educates patients and family members about the risk of

CDI with antibiotics.

Yes | No

Environmental

Cleaning

1 Hospital has a competency-based training program for

environmental cleaning.

Yes | No

Environmental

Cleaning

N/A Training program includes the following: N/A

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Hospital

Assessment

Section


Environmental

Cleaning

1a Training is provided to all personnel who clean and disinfect patient

care areas. Personnel may include, but are not limited to,

environmental services staff, nurses, nursing assistants, and

technicians.

Yes | No

Environmental

Cleaning

1b Training is provided upon hire, prior to being allowed to perform

environmental cleaning.

Yes | No

Environmental

Cleaning

1c Training is provided at least annually. Yes | No

Environmental

Cleaning

1d Training is provided when new equipment or protocols are

introduced.

Yes | No

Environmental

Cleaning

1e Personnel are required to demonstrate competency with

environmental cleaning (i.e., correct technique is observed by

trainer) following each training.

Yes | No

Environmental

Cleaning

1f Hospital maintains current documentation of competency with

environmental cleaning procedures for all personnel who clean and

disinfect patient care areas.

Yes | No

Environmental

Cleaning

1g If the hospital contracts environmental services, the contractor has a

comparable training program.


Environmental

Cleaning

2 Hospital has policies that clearly define responsibilities for cleaning

and disinfection of non-critical equipment, mobile devices, and

other electronics (e.g., ICU monitors, ventilator surfaces, bar code

scanners, point-of-care devices, mobile work stations, code carts,

airway boxes).

Yes | No

Environmental

Cleaning

3 Hospital has protocols to ensure that healthcare personnel can

readily identify equipment that has been properly cleaned and

disinfected and is ready for patient use (e.g., tagging system,

placement in dedicated clean area).

Yes | No

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Hospital

Assessment

Section


Environmental

Cleaning

4 Hospital regularly audits (monitors and documents) adherence to

cleaning and disinfection procedures, including use of products in

accordance with manufacturers' instructions (e.g., dilution, storage,

shelf-life, contact time).

Yes | No

Environmental

Cleaning

5 Hospital provides feedback from audits to personnel regarding their

adherence to cleaning and disinfection procedures.

Yes | No

Device

Reprocessing

1 Hospital has a competency-based training program for reprocessing

of critical devices.

Yes | No

Device

Reprocessing

1a Training is provided to all personnel who reprocess critical devices. Yes | No

Device

Reprocessing

1b Training is provided upon hire, prior to being allowed to reprocess

critical devices.

Yes | No

Device

Reprocessing


Device

Reprocessing

1d Training is provided when new devices or protocols are introduced. Yes | No

Device

Reprocessing

1e Personnel are required to demonstrate competency with device

reprocessing (i.e., correct technique is observed by trainer)


Yes | No

Device

Reprocessing


reprocessing procedures for all personnel who reprocess critical

devices.

Yes | No

Device

Reprocessing

1g If the hospital contracts reprocessing of critical devices, the

contractor has a comparable training program which includes the

specific devices used by the hospital.


Device

Reprocessing


reprocessing procedures for critical devices.

Yes | No

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Hospital

Assessment

Section


Device

Reprocessing

2a Audits occur in all locations where critical devices are reprocessed

(e.g., central sterile reprocessing, operating suites), including

locations where initial cleaning steps are performed (e.g., point of

use).

Yes | No

Device

Reprocessing


adherence to reprocessing procedures for critical devices.

Yes | No

Device

Reprocessing

4 Hospital has a competency-based training program for reprocessing

of semi-critical devices.

Yes | No

Device

Reprocessing

4a Training is provided to all personnel who reprocess semi-critical

devices.

Yes | No

Device

Reprocessing

4b Training is provided upon hire, prior to being allowed to reprocess

semi-critical devices.

Yes | No

Device

Reprocessing


Device

Reprocessing

4d Training is provided when new devices or protocols are introduced. Yes | No

Device

Reprocessing

4e Personnel are required to demonstrate competency with device

reprocessing (i.e., correct technique is observed by trainer)


Yes | No

Device

Reprocessing


reprocessing procedures for all personnel who reprocess semi-

critical devices.

Yes | No

Device

Reprocessing

4g If the hospital contracts reprocessing of semi-critical devices, the

contractor has a comparable training program which includes the

specific devices used by the hospital.


Device

Reprocessing


reprocessing procedures for semi-critical devices.

Yes | No

ICAR HAI User Guide

Page 35 of 79

Hospital

Assessment

Section


Device

Reprocessing

5a Audits occur in all locations where semi-critical devices are

reprocessed (e.g., central sterile reprocessing, endoscopy suites),

including locations where initial cleaning steps are performed (e.g.,

point of use).

Yes | No

Device

Reprocessing


adherence to reprocessing procedures for semi-critical devices.

Yes | No

Device

Reprocessing

7 Hospital reuses single-use devices. Yes | No

Device

Reprocessing

7a If yes, the single-use devices are reprocessed by an FDA-approved

entity.


Device

Reprocessing

8 Hospital maintains documentation of reprocessing activities. Yes | No

Device

Reprocessing

N/A Documentation includes the following: N/A

Device

Reprocessing

8a Hospital maintains logs for each sterilizer cycle that include the

results from each load.

Yes | No

Device

Reprocessing

8b Hospital has documentation that the chemicals used for high-level

disinfection are routinely tested for appropriate concentration and

replaced appropriately.

Yes | No

Device

Reprocessing

9 Hospital allows adequate time for reprocessing to ensure adherence

to all steps recommended by the device manufacturer, including

drying and proper storage.

Yes | No

Device

Reprocessing

9a Hospital has an adequate supply of instruments for the volume of

procedures performed to allow sufficient time for all reprocessing

steps.

Yes | No

Device

Reprocessing

9b Scheduling of procedures allows sufficient time for all reprocessing

steps.

Yes | No

Device

Reprocessing

9c Hospital rarely/never uses immediate-use steam sterilization

(IUSS).

Yes | No

ICAR HAI User Guide

Page 36 of 79

Hospital

Assessment

Section


Device

Reprocessing

10 IP program is consulted whenever new devices or products will be

purchased or introduced to ensure implementation of appropriate

reprocessing policies and procedures.

Yes | No

Device

Reprocessing

11 Hospital has policies and procedures outlining hospital response

(i.e., risk assessment and recall of device) in the event of a

reprocessing error or failure.

Yes | No

Device

Reprocessing

11a Hospital has a procedure to identify which patients may have been

exposed to an improperly reprocessed device.

Yes | No

MDROs 1 Hospital has system in place for early detection and management of

potentially infectious persons at initial points of entry to the

hospital, including rapid isolation as appropriate.

Yes | No

MDROs 1a Travel and occupational history are included as part of admission

and triage protocols.

Yes | No

MDROs 1b Hospital has system to identify (flag) patients with targeted

MDROs upon readmission so appropriate precautions can be

applied.

Yes | No

MDROs 2 The hospital has a respiratory/hygiene cough etiquette program. Yes | No

MDROs N/A The etiquette program includes the following: N/A

MDROs 2a Posting signs at entrances. Yes | No

MDROs 2b Providing tissues and no-touch receptacles for disposal of tissues. Yes | No

MDROs 2c Providing hand hygiene supplies in or near waiting areas. Yes | No

MDROs 2d Offering face masks to coughing patients and other symptomatic

individuals upon entry to the facility.

Yes | No

MDROs 2e Providing space in patient waiting areas (e.g., ED waiting room)

and encouraging individuals with symptoms of respiratory

infections to sit as far away from others as possible.

Yes | No

MDROs 3 Hospital has systems in place for early detection and isolation of

infectious patients identified during the hospital stay, including

rapid isolation of patients as appropriate.

Yes | No

ICAR HAI User Guide

Page 37 of 79

Hospital

Assessment

Section


MDROs 3a There is a mechanism for prompt notification of the IP by the

clinical microbiology laboratory when novel resistance patterns

and/or targeted antimicrobial-resistant pathogens are detected.

Yes | No

MDROs 4 Hospital has system in place for INTER-facility communication of

infectious status and isolation needs of patients prior to transfer to

other facilities.

Yes | No

MDROs 4a The hospital has system to notify receiving facilities of

microbiological tests (e.g. cultures) that are pending at the time of

transfer.

Yes | No

MDROs 5 Hospital has system in place for INTER-facility communication to

identify infectious status and isolation needs of patients prior to

accepting patients from other facilities.

Yes | No

MDROs 5a The hospital has system to follow-up on microbiological results

(e.g., cultures) that are pending at the time of transfer.

Yes | No

MDROs 5b If the hospital identifies an infection that may be related to care

provided at another facility (e.g., hospital, nursing home, clinic), the

facility is notified.

Yes | No

MDROs 6 Hospital has system in place for INTRA-facility communication to

identify infectious status and isolation needs of patients prior to

transfer to other units or shared spaces (e.g., radiology, physical

therapy, emergency department) within the hospital.

Yes | No

MDROs 6a IP ensures infectious status and isolation needs are communicated

with receiving units.

Yes | No

MDROs 7 Hospital has a surveillance program to monitor incidence of

epidemiologically-important organisms (e.g., CRE) and targeted

healthcare-associated infections.

Yes | No

MDROs 7a IP is familiar with how the hospital determines which organisms

and HAIs to track.

Yes | No

ICAR HAI User Guide

Page 38 of 79

Hospital

Assessment

Section


MDROs 8 Hospital uses surveillance data to implement corrective actions

rapidly when transmission of epidemiologically-important

organisms (e.g., CRE) or increased rates or persistently elevated

rates of healthcare-associated infections are detected.

Yes | No

MDROs 8a Data collection method allows for timely response to identified

problems.

Yes | No

MDROs 9 Hospital has an antibiotic stewardship program that meets the 7

CDC core elements listed below (a-g).

Yes | No

MDROs 9a Hospital leadership commitment: Hospital has a written statement

of support from leadership that supports efforts to improve

antibiotic use (antibiotic stewardship) AND/OR hospital provides

salary support for dedicated time for antibiotic stewardship

activities.

Yes | No

MDROs 9b Program leadership (accountability): There is a leader responsible

for outcomes of stewardship activities at the hospital.

Yes | No

MDROs 9c Drug expertise: There is at least one pharmacist responsible for

improving antibiotic use at the hospital.

Yes | No

ICAR HAI User Guide

Page 39 of 79

Hospital

Assessment

Section


MDROs 9d Act (at least one prescribing improvement action below):Hospital

has a policy that requires prescribers to document an indication for

all antibiotics in the medical record or during order entry.Hospital

has hospital-specific treatment recommendations, based on national

guidelines and local susceptibility, to assist with antibiotic selection

for common clinical conditions.There is a formal procedure for all

clinicians to review the appropriateness of all antibiotics at or after

48 hours from the initial orders (e.g., antibiotic time out).Hospital

has specified antibiotic agents that need to be approved by a

physician or pharmacist prior to dispensing at the hospital.Physician

or pharmacist reviews courses of therapy for specified antibiotic

agents and communicates results with prescribers.

Yes | No

MDROs 9e Track: Hospital monitors antibiotic use (consumption). Yes | No

MDROs 9f Report: Prescribers receive feedback by the stewardship program

about how they can improve their antibiotic prescribing.

Yes | No

MDROs 9g Educate: Stewardship program provides education to clinicians and

other relevant staff on improving antibiotic use.

Yes | No

MDROs 10 Hospital has an occupational health program that, in addition to

complying with state and federal requirements (e.g., OSHA), has

policies regarding contact of personnel with patients when

personnel have potentially transmissible conditions.

Yes | No

ICAR HAI User Guide

Page 40 of 79

Hospital

Assessment

Section


MDROs 10a The program has work-exclusion policies that encourage reporting

of illnesses and do not penalize with loss of wages, benefits or job

status.

Yes | No

MDROs 10b Personnel are educated regarding prompt reporting of illness to

their supervisor and the occupational health programs.

Yes | No

MDROs 11 Hospital follows recommendations of the Advisory Committee on

Immunization Practices (ACIP) for immunization of healthcare

personnel, including offering Hepatitis B and influenza vaccination.

Yes | No

MDROs 12 Hospital is compliant with mandatory reporting requirements for

notifiable diseases, healthcare-associated infections (as

appropriate), and potential outbreaks.

Yes | No

MDROs 12a Hospital can identify point(s) of contact at the local or state health

department for HAI concerns

Yes | No

MDROs 13 Hospital implements infection control measures relevant to

construction, renovation, demolition, and repairs including

performance of an infection control risk assessment (ICRA) before

a project gets underway.

Yes | No

MDROs 13a IP program is consulted anytime construction, renovation,

demolition or repairs will be performed.

Yes | No

MDROs 13b ICRA elements are included in all contracts related to construction,

renovation, demolition, and repairs.

Yes | No

NHSN 1 Infection Preventionist knows how to import data into NHSN. Yes | No

NHSN 2 Infection Preventionist knows how to export data from NHSN. Yes | No

NHSN 3 Infection Preventionist uses analysis tools within NHSN. Yes | No

NHSN 4 How many times per month does the Infection Preventionist login

to NHSN?

0 | 1 | 2 or more

NHSN 5 Hospital monitors HAI data and uses data to direct prevention

activities.

Yes | No

NHSN 6 Hospital provides feedback of NHSN data to frontline personnel. Yes | No

ICAR HAI User Guide

Page 41 of 79

Hospital

Assessment

Section


NHSN 7 How often are HAI surveillance reports (NHSN data and/or other

HAI data) disseminated within your hospital?

Quarterly | Monthly | Weekly | Ad

Hoc | Never

NHSN 8 Who receives surveillance reports (NHSN data and/or other HAI

data)? (Select all that apply.)

Physicians | Nurses | C-Level |

Quality Improvement | We do not

disseminate surveillance reports /

Not Applicable | Other

NHSN 8a What level of detail is included in your reports? Line Level / Patient Record Level

data only | Aggregate data only |

Combination of line level / patient

record level and aggregate |

Reports are customized for each

department | We do not

disseminate surveillance reports /

not applicable | Other

ICAR HAI User Guide

Page 42 of 79

Dialysis Assessment Questions

Dialysis

Assessment

Section

Question

#

Question Possible Answers (if applicable)

Facility

Information

1 Rationale for Assessment (Select all that

apply):

Outbreak | Input from ESRD Network or state survey agency |

Participation in Infection Control and Response (ICAR) |

Recommendation of accrediting organization or state survey

agency | Increase in healthcare-associated infections | Participation

in Prevention Collaborative | Other

Facility

Information

2 If you selected "Increase in healthcare-

associated infections" above, please select

infection types that have increased. (Select

all that apply)

Bloodstream Infection (BSI) | Vascular Access Infection (VAI) |

Local Access Site Infection (LASI) | Access-related Bloodstream

Infection (ARBI) | Other

Facility

Information

3 Who staffs the facility? (Select all that

apply)

Hospital Staff | Contract with a dialysis company | Dialysis center

employs staff directly | Other

Facility

Information

4 Please indicate this facility's association

with a dialysis chain:

DaVita | Fresenius Medical Care | Dialysis Clinic, Inc. (DCI) |

This facility is NOT part of a dialysis chain | Other

Facility

Information

5 What services are offered at the facility?

(Select all that apply)

Adult in-center hemodialysis | Pediatric in-center hemodialysis |

Home hemodialysis |Nocturnal hemodialysis |Peritoneal dialysis |

Inpatient hemodialysis (in addition to outpatient hemodialysis)

Facility

Information

6 What is the typical daily patient census?

(include all dialysis patients cared for by the

facility)

1-25 | 26-50 | 51-75 | 76-100 | 101-150 | 151-200 | > 200

Infrastructure 1 What training does the person in charge of

infection control at the facility have? Select

the best answer.

Certified in Infection Control (CIC) | No specific training in

infection control | Not applicable (no person in charge of infection

control at the facility) | Other

ICAR HAI User Guide

Page 43 of 79

Dialysis

Assessment

Section

Question

#


Infrastructure 2 Is the facility participating in their ESRD

Network Healthcare-Associated Infection

(HAI) Quality Improvement Activity

(QIA)?

Yes | No

Infrastructure 3 Has the facility participated in the CDC

Dialysis BSI Prevention Collaborative?

Yes | No

Infrastructure 4 In the past two years, has the facility

participated in any other intensive program

focused on HAI prevention? (e.g., clinical

trial, company-led quality improvement

project)

Yes | No

Infrastructure 4a If yes, please specify:

Infrastructure 5 Does the facility have a system for early

detection and management of potentially

infectious persons at initial points of patient

encounter? Note: System may include

taking a travel history, assessing for

diarrhea or draining infected wounds, and

elements described under respiratory

hygiene/cough etiquette.

Yes, system applies at (or prior to) point of facility check-in | Yes,

system applies when patient arrives in dialysis treatment area | No

Infrastructure 6 Does the facility have a policy/protocol for

implementing Contact Precautions when

warranted? Note: CDC does not

recommend Contact Precautions for

multidrug resistant organisms (MDROs) in

dialysis clinics. However, in certain

circumstances (e.g., known or suspected

MDRO transmission), Contact Precautions

may be necessary.

Yes | No

ICAR HAI User Guide

Page 44 of 79

Dialysis

Assessment

Section

Question

#


Infrastructure 7 Are there signs posted in the facility that

encourage patients to take an active role in

and express their concerns about facility

infection control practices?

Yes | No

Infrastructure 8 Does the facility provide standardized

education to all patients on vascular access

care?

Yes | No


education to all patients on hand hygiene?

Yes | No


education to all patients on risks related to

catheter use?

Yes | No


education to all patients on recognizing

signs of infection?

Yes | No


education to all patients on instructions for

access management when away from the

dialysis unit?

Yes | No

Infrastructure 13 What is the distance separating adjacent

dialysis treatment stations?

Embedded/shared computer terminal (0 feet) | < 3 feet | 3 feet - 6

feet | 6 feet or more

Infrastructure 13a If using an embedded/shared computer

terminal, what is the policy/protocol for

routinely cleaning the embedded/shared

computer terminal?

Computer terminal is cleaned after each patient | Computer

terminal is cleaned after each shift | Computer terminal is cleaned

at the end of each day | Facility does not have a policy/protocol for

routinely cleaning the computer terminal | Not Applicable | Other

Infrastructure 14 Does the facility have an isolation room that

is available for isolation of conditions other

than hepatitis B? (i.e., not currently in use

for hepatitis B patients?)

Yes | No

ICAR HAI User Guide

Page 45 of 79

Dialysis

Assessment

Section

Question

#


Infrastructure 15 Does the facility use hemodialysis machine

Waste Handling Option (WHO) ports?

(Note: the WHO port is a machine port used

for prime waste.)

Yes | No

Infrastructure 15a If yes, does the facility have a

policy/protocol in place for disinfecting the

WHO port?


Infrastructure 16 Are patients in the facility ever "bled onto

the machine" (i.e., where blood is allowed

to reach or almost reach the prime waste

receptacle or WHO port)? (Note: This

practice is discouraged because it can result

in patient blood loss and blood

contamination of the environment.)

Yes | No

Audits 1 Does the facility provide job-specific

training to healthcare personnel (HCP) on

infection prevention policies and

procedures upon hire, prior to provision of

care? Note: This includes those employed

by outside agencies and available by

contract or on a volunteer basis to the

facility.

Yes | No

Audits 2 Does the facility provide job-specific

training to healthcare personnel (HCP) on


procedures at least annually? Note: This

includes those employed by outside

agencies and available by contract or on a

volunteer basis to the facility.

Yes | No

ICAR HAI User Guide

Page 46 of 79

Dialysis

Assessment

Section

Question

#


Audits 3 Does the facility assess and document

competency (i.e., correct technique

observed by a trainer) with job-specific


procedures upon hire, prior to provision of

care?

Yes | No

Audits 4 Does the facility assess and document

competency (i.e., correct technique

observed by a trainer) with job-specific


procedures at least annually?

Yes | No

Audits 5 Does the facility routinely audit staff

infection control practice (i.e.,

systematically collect and monitor data)?

Yes | No

Audits 5a If yes, does the facility provide feedback on

adherence to clinical staff?


ICAR HAI User Guide

Page 47 of 79

Dialysis

Assessment

Section

Question

#


Audits 6 Does the facility routinely use standardized

tools for educating staff and/or assessing

practice? (Select all that apply)

No standardized tools used | AHRQ/CMS Checklist Tools |

Corporate Tools | CDC Video: Preventing BSIs in Outpatient

Hemodialysis Patients: Best Practices for Dialysis Staff | CDC

Approach to BSI Prevention in Dialysis Facilities (i.e., Core

Interventions for Dialysis BSI Prevention) | CDC Hemodialysis

Central Venous Catheter Scrub-the-Hub Protocol | CDC Dialysis

Audit tools for Hand Hygiene | CDC Dialysis Audit tools for

catheter connection & disconnection | CDC Dialysis Audit tools

for catheter exit site care | CDC Dialysis Audit tools for

arteriovenous fistula and graft cannulation and decannulation |

CDC Dialysis Audit tools for injectable medication preparation

and administration | CDC Dialysis Audit tools for routine

disinfection of dialysis station | CDC Dialysis checklists for

catheter connection & disconnection | CDC Dialysis checklists for

catheter exit site care | CDC Dialysis checklists for arteriovenous

fistula and graft cannulation and decannulation | CDC Dialysis

checklists for injectable medication preparation and administration

| CDC Dialysis checklists for routine disinfection of dialysis

station | Other

HCP Safety 1 Does the facility provide post-exposure

evaluation and follow-up, including

prophylaxis as appropriate, to healthcare

personnel (HCP) at no cost following an

exposure event?

Yes | No

HCP Safety 2 Does the facility track HCP exposure

events, evaluate event data and

develop/implement correction action plans

to reduce incidence of such events?

Yes | No

ICAR HAI User Guide

Page 48 of 79

Dialysis

Assessment

Section

Question

#


HCP Safety 3 Does the facility offer hepatitis B vaccine to

personnel who may be exposed to blood or

body fluids through their job duties?

Yes | No

HCP Safety 4 Does the facility offer influenza vaccine to

all personnel?

Yes | No

HCP Safety 5 Does the facility conduct baseline

tuberculosis (TB) screening of healthcare

personnel?

Yes | No

HCP Safety 6 Does the facility have work-exclusion

policies that encourage reporting of

illnesses and do not penalize with loss of

wages, benefits, or job status?

Yes | No

HCP Safety 7 Does the facility educate healthcare

personnel on prompt reporting of illness or

job-related injury to supervisor and/or

occupational health?

Yes | No

Surveillance 1 Does someone in the facility know the

facility's bloodstream infection (BSI) rate in

NHSN or BSI standardized infection ratio

(SIR)?

Yes | No | Not Applicable (data are not reported to NHSN)

Surveillance 1a If yes, does the facility share rate data with

front-line clinical staff?


Surveillance 2 Does the facility have a policy that

mandates blood culture collection before

antimicrobial administration any time a BSI

is suspected?

Yes | No

ICAR HAI User Guide

Page 49 of 79

Dialysis

Assessment

Section

Question

#


Surveillance 3 Does the facility conduct routine screening

of hemodialysis patients for hepatitis C

antibody at the recommended interval? (on

admission and 6 months thereafter for

susceptible patients)

Yes | No

Surveillance 4 Does the facility know how to report

clusters of infections, adverse events, or a

new hepatitis B/C case to public health?

Yes | No

Surveillance 5 Does the facility have a system in place to

communicate infection or colonization with

a multidrug resistant organism (MDRO) to

other healthcare facilities upon transfer?

Yes | No

Respiratory 1 Does the facility have signs posted at

entrances with instructions to patients with

symptoms of respiratory infection to cover

their mouth/nose when coughing or

sneezing, use and dispose of tissues, and

perform hand hygiene after contact with

respiratory secretions?

Yes | No

Respiratory 2 Does the facility provide a means for

patients to perform hand hygiene in or near

waiting areas?

Yes | No

Respiratory 3 Does the facility provide space and

encourage persons with symptoms of

respiratory infection to sit as far away from

others as possible?

Yes | No

Respiratory 4 Does the facility provide tissues and no-

touch receptacles for disposal of tissues?

Yes | No

ICAR HAI User Guide

Page 50 of 79

Dialysis

Assessment

Section

Question

#


Respiratory 5 Does the facility offer face masks upon

facility entry to patients with symptoms of

respiratory infection?

Yes | No

Respiratory 6 Does the facility have the ability to separate

symptomatic patients (by at least 6 feet)

from other patients and their stations during

dialysis treatment?

Yes | No

PPE 1 Does the facility provide job-specific

training to HCP on proper selection and use

of PPE upon hire, prior to provision of

care?

Yes | No

PPE 2 Does the facility provide job-specific

training to HCP on proper selection and use

of PPE at least annually?

Yes | No

PPE 3 Does the facility validate competency (i.e.,

correct technique observed by a trainer)

with use of PPE?

Yes | No

PPE 4 Are gloves available and located near point

of use?

Yes | No

PPE 5 Are gowns available and located near point

of use?

Yes | No

PPE 6 Are face shields/eye protection available

and located near point of use?

Yes | No

PPE 7 Are face masks available and located near

point of use?

Yes | No

ICAR HAI User Guide

Page 51 of 79

Dialysis

Assessment

Section

Question

#


PPE 8 Does the facility have a policy /protocol for

staff to routinely change/launder gowns (in

the absence of soilage)? Note: this question

applies to staff caring for patients in the

general treatment area, not patients in

isolation.

Yes, at the end of the shift | Yes, at the end of the day | No | Other

Environmental 1 Does the facility have written policies and

procedures for routine cleaning and

disinfection of environmental surfaces,

including clearly defining responsible

personnel? Note: Policy and procedures

should identify staff responsible for

performing cleaning and disinfection as

well as those responsible for selection and

preparation of disinfectant solution(s).

Yes | No

Environmental 2 Do personnel who clean and disinfect

patient care areas (e.g., environmental

services, technicians, nurses) receive

training on cleaning procedures upon hire,

prior to being allowed to perform

environmental cleaning? Note: If

environmental cleaning is performed by

contract personnel, facility should verify

this is provided by contracting company.

Yes | No

ICAR HAI User Guide

Page 52 of 79

Dialysis

Assessment

Section

Question

#





training on cleaning procedures at least

annually? Note: If environmental cleaning

is performed by contract personnel, facility

should verify this is provided by contracting

company.

Yes | No




training on cleaning procedures when

policies and/or procedures change? Note: If

environmental cleaning is performed by

contract personnel, facility should verify


Yes | No

Environmental 5 Does the facility regularly audit adherence

to cleaning and disinfection procedures

(i.e., systematically collect and monitor

data)?

Yes | No

Environmental 6 Does the facility have a policy /procedure

for decontamination of spills of blood or

other body fluids?

Yes | No

Environmental 6a Are supplies necessary to clean the blood

spill (e.g., proper disinfectant or spill kit)

readily available and located near point of

use?

Yes | No

ICAR HAI User Guide

Page 53 of 79

Dialysis

Assessment

Section

Question

#


Environmental 7 Does the facility have policies/procedures

for emptying reusable waste containers

(e.g., leakproof containers used for disposal

of used dialyzers and tubing)?

Yes | No

Environmental 8 Does the facility have policies/procedures

for cleaning reusable waste containers (e.g.,

leakproof containers used for disposal of

used dialyzers and tubing)?

Yes | No

Environmental 9 Does the facility have policies and

procedures to ensure reusable medical

devices (e.g., thermometers, stethoscopes,

blood pressure cuffs) are cleaned

appropriately between patients?

Yes | No | Not Applicable (no reusable medical devices are used at

the facility)


procedures for routinely cleaning and

disinfecting dialysis clamps?

Yes | No | Not Applicable (facility does not use dialysis clamps)



disinfecting blood glucose monitors?

Yes | No | Not Applicable (facility does not use blood glucose

monitors)



disinfecting Dialysate Conductivity/pH

meter(s)?

Yes | No | Not Applicable (facility does not use Dialysate

Conductivity/pH meter(s))

Dialyzer N/A Does your facility reuse dialyzers?

((If answer is no, Dialyzer section is

considered complete)

Yes | No

Dialyzer 1 Does the facility document informed

consent for patients who participate in

dialyzer reuse?

Yes | No

ICAR HAI User Guide

Page 54 of 79

Dialysis

Assessment

Section

Question

#


Dialyzer 2 Does the facility have policies and

procedures to ensure that dialyzers are

cleaned and reprocessed appropriately prior

to reuse? Note: if reprocessing is performed

off-site, facility policies and procedures

should address safe handling of used

dialyzers prior to reprocessing and

assessment of disinfection process after

reprocessing.

Yes | No

Dialyzer 3 If dialyzers are reprocessed on-site, does the

facility train personnel responsible for

reprocessing dialyzers on proper selection

and use of PPE and recommended steps for

reprocessing equipment?



facility test the competency (i.e., observe

correct technique by a trainer) of personnel

responsible for reprocessing dialyzers upon

hire, prior to being allowed to reprocess

dialyzers?



facility test the competency (i.e., observe

correct technique by a trainer) of personnel

responsible for reprocessing dialyzers at

least annually?


ICAR HAI User Guide

Page 55 of 79

Dialysis

Assessment

Section

Question

#



facility regularly audit adherence to

reprocessing procedures (i.e., systematically

collect and monitor data) and provide

feedback to personnel regarding their

performance?



facility perform routine maintenance for

reprocessing equipment (e.g., automated

reprocessors) by qualified personnel in

accordance with manufacturer instructions?

Yes | No | Only manual reprocessing methods used | Not

Applicable

Hand Hygiene 1 Alcohol-based hand gel is available and

located near point of use.

Yes | No

Hand Hygiene 2 Handwashing sinks are available and

located near point of use.

Yes | No

Hand Hygiene 3 Soap is available and located near point of

use.

Yes | No

Hand Hygiene 4 Paper towels are available and located near

point of use.

Yes | No

Hand Hygiene 5 Does the facility perform observations of

staff hand hygiene opportunities monthly

(or more frequently)?

Yes | No

Hand Hygiene 5a If yes, does the facility provide feedback on



Catheter 1 Does the facility provide specific training to

catheter/vascular access care and aseptic

technique for staff handling catheters and/or

vascular accesses?

Yes | No

ICAR HAI User Guide

Page 56 of 79

Dialysis

Assessment

Section

Question

#


Catheter 2 Does the facility perform observations of

staff vascular access care and catheter

accessing practices quarterly (or more

frequently)?

Yes | No

Catheter 2a If yes, does the facility provide feedback on



Catheter 3 Does the facility perform staff competency

assessments (i.e., correct technique

observed by a trainer) for vascular access

care and catheter accessing upon hire, prior

to provision of care?

Yes | No

Catheter 4 Does the facility perform staff competency

assessments (i.e., correct technique

observed by a trainer) for vascular access

care and catheter accessing at least

annually?

Yes | No

Catheter 5 Does the facility use an alcohol-based

chlorhexidine (> 0.5%) solution as the first

line skin antiseptic agent during dressing

changes of catheters?

Yes | No

ICAR HAI User Guide

Page 57 of 79

Dialysis

Assessment

Section

Question

#


Catheter 6 Does the facility routinely apply an

antibiotic ointment or povidine-iodine

ointment to catheter exit sites during

dressing changes? Note: CDC recommends

using povidine iodine ointment or

bacitracin/gramicidin/polymyxin B

ointment (not currently available in the

United States). Triple antibiotic ointment

(bacitracin/neomycin/polymyxin B) is

available and might have similar benefit.

Mupirocin ointment is not recommended

due to concerns about development of

antimicrobial resistance.

Yes | No ointment used, but chlorhexidine dressing used | Neither

ointment nor chlorhexidine dressing used

Catheter 7 Does the facility routinely scrub catheter

hubs with appropriate antiseptic after the

caps are removed and before accessing the

catheter?

Yes | No | Not Applicable. Facility uses needleless connector

devices.

Catheter 7 If facility uses needleless connector

devices, does the facility routinely scrub the

catheter hubs when the needleless

connectors are removed?

Yes | No | Not Applicable. Facility does NOT use needleless

connector devices.

Injection

Safety

1 Sharps containers are available and located

near point of use:

Yes | No

Injection

Safety

2 Needles/cannulae with safety feature are

available and located near point of use:

Yes | No

Injection

Safety

3 Does the facility have policies/procedures

to ensure sharps containers are emptied

and/or changed on a regular basis and when

needed?

Yes | No

ICAR HAI User Guide

Page 58 of 79

Dialysis

Assessment

Section

Question

#


Injection

Safety

4 Does the facility use a clean room that is

physically separate from the treatment area

for storage and preparation of injectable

medications?

Yes | No

Injection

Safety

4a If no, is there a room available in the

facility that could be used for storage and

preparation of injectable medications?


Injection

Safety

5 Does the facility have a policy/procedure

for routinely cleaning surface(s) where

injectable medications are prepared?

Yes | No

Injection

Safety

6 Does the facility use manufacturer pre-filled

saline syringes or single-use saline vials for

flushes?

Yes | No, flushes are drawn from the patient's designated saline

bag used for dialysis | No, flushes are drawn up from the patient's

dialysis line | No, flushes are drawn from a common saline bag

used for all patients | Other

ICAR HAI User Guide

Page 59 of 79

LTCF Assessment Questions

LTCF Assessment

Section

Question # Question Answers Options (if

applicable)

Facility Info 1

Rationale for Assessment (Select all that apply): Outbreak | Participation in

Infection Control and

Response (ICAR) |

Recommendation of

accrediting organization or

state survey agency |

Increase in healthcare-

associated infections |

Participation in Prevention

Collaborative | Other

Facility Info 2

If you selected "Increase in healthcare-associated infections" above, please

select infection types that have increased. (Select all that apply)

Bloodstream Infections |

Multidrug Resistant

Organisms (MDRO) |

Catheter-associated Urinary

Tract Infection (CAUTI) |

Clostridium difficile

Infections (CDI) |

Pneumonia / Respiratory |

Wound Infections | Other

Facility Info 3 Is the facility licensed by the state? Yes | No

Facility Info 4 Is the facility certified by the Centers for Medicare & Medicaid Services

(CMS)?

Yes | No

Facility Info 5 Facility type (please select your official DHSR designation): Nursing Home | Adult Care

Home | Assisted Living

Facility | Other

Facility Info 6 Number of licensed beds:

ICAR HAI User Guide

Page 60 of 79

LTCF Assessment

Section


applicable)

Facility Info 7 Total staff hours per week on average dedicated to infection prevention and

control activities:

Infrastructure 1 The facility has specified a person (e.g., staff consultant) who is responsible

for coordinating the IC program.

Yes | No

Infrastructure 2 The person responsible for coordinating the infection prevention program

has received training in IC. Examples of training may include: successful

completion of initial and/or recertification exams developed by the

Certification Board for Infection Control and Epidemiology; Participation

in infection control courses organized by the state or recognized

professional societies or universities (e.g., APIC, SHEA, NADONA-LTC,

SPICE).

Yes | No

Infrastructure 3 The facility has a process for reviewing infection surveillance data and

infection prevention activities (e.g., presentation at QA committee).

Yes | No

Infrastructure 4 Written infection control policies and procedures are available and based on

evidence-based guidelines (e.g., CDC/HICPAC), regulations (F-441), or

standards. Note: policies and procedures should be tailored to the facility

and extend beyond OSHA bloodborne pathogen training or the CMS State

Operations Manual.

Yes | No

Infrastructure 5 Written infection control policies and procedures are reviewed at least

annually or according to state or federal requirements, and updated if

appropriate.

Yes | No

Infrastructure 6 The facility has a written plan for emergency preparedness (e.g., pandemics

or natural disasters).

Yes | No

HCP Safety 1 The facility has work-exclusion policies for personnel who have potentially

transmissible conditions. These policies encourage avoiding contact with

residents and do not penalize with loss of wages, benefits, or job status.

Yes | No

HCP Safety 2 The facility educates personnel on prompt reporting of signs/symptoms of a

potentially transmissible illness in residents and/or personnel to a

supervisor.

Yes | No

ICAR HAI User Guide

Page 61 of 79

LTCF Assessment

Section


applicable)

HCP Safety 3 The facility conducts baseline Tuberculosis (TB) screening for all new

personnel in all departments.

Yes | No

HCP Safety 4 The facility has a policy to assess healthcare personnel risk for TB (based

on regional, community data) and requires periodic (at least annual) TB

screening if indicated.

Yes | No

HCP Safety 5 The facility offers Hepatitis B vaccination to all personnel who may be

exposed to blood or body fluids as part of their job duties.

Yes | No

HCP Safety 6 The facility offers all personnel influenza vaccination annually. Yes | No

HCP Safety 7 The facility maintains written records of personnel influenza vaccination

from the most recent influenza season.

Yes | No

HCP Safety 8 The facility has an exposure control plan which addresses potential hazards

posed by specific services provided by the facility (e.g., blood-borne

pathogens). Note: A model template, which includes a guide for creating an

exposure control plan that meets the requirements of the OSHA Bloodborne

Pathogens Standard is available at

https://www.osha.gov/Publications/osha3186.pdf.

Yes | No

HCP Safety 9 All personnel receive training on managing a blood-borne pathogen

exposure at the time of employment. Note: an exposure incident refers to a

specific eye, mouth, other mucous membrane, non-intact skin, or parenteral

contact with blood or other potentially infectious materials that results from

the performance of an individual's duties.

Yes | No

HCP Safety 10 All personnel receive competency validation on managing a blood-borne

pathogen exposure at the time of employment. Note: an exposure incident

refers to a specific eye, mouth, other mucous membrane, non-intact skin, or

parenteral contact with blood or other potentially infectious materials that

results from the performance of an individual's duties.

Yes | No

HCP Safety 11 All personnel received training on managing a potential blood-borne

pathogen exposure within the past 12 months and know how to report

exposures.

Yes | No

ICAR HAI User Guide

Page 62 of 79

LTCF Assessment

Section


applicable)

HCP Safety 12 All personnel received competency validation on managing a potential

blood-borne pathogen exposure within the past 12 months.

Yes | No

HCP Safety 13 Resident Safety: The facility currently has a written policy to assess risk for

TB (based on regional, community data) and provide screening to residents

on admission.

Yes | No

HCP Safety 14 Resident Safety: The facility documents pneumococcal vaccination status at

time of admission for incoming residents.

Yes | No

HCP Safety 15 Resident Safety: The facility offers annual influenza vaccination to

residents.

Yes | No

Surveillance 1 The facility has written intake procedures to identify potentially infectious

persons at the time of admission. Examples: documenting recent antibiotic

use, and history of infections or colonization with C. difficile or antibiotic

resistant organisms.

Yes | No

Surveillance 2 The facility has a system in place to notify the infection preventionist (IC

nurse) when antibiotic-resistant organisms or C. difficile are reported by the

clinical laboratory.

Yes | No

Surveillance 3 The facility has a written surveillance plan outlining the activities for

monitoring/tracking infections occurring in residents of the facility.

Yes | No

Surveillance 4 The facility has a system in place to receive more detailed clinical

information (e.g., laboratory, procedure results and diagnoses) from

hospitals IN ADDITION TO DISCHARGE SUMMARIES when residents

are transferred to acute care hospitals for management of suspected

infections, including sepsis.

Yes | No

Surveillance 5 The facility has a written plan for outbreak response which includes a case

definition for the outbreak, procedures for surveillance and containment,

and a list of syndromes or pathogens for which monitoring is performed.

Yes | No

Surveillance 6 The facility has access to a current list of diseases reportable to public

health authorities.

Yes | No

ICAR HAI User Guide

Page 63 of 79

LTCF Assessment

Section


applicable)

Surveillance 7 The facility can provide point(s) of contact at the local or state health

department for assistance with outbreak response.

Yes | No

Hand Hygiene 1 The facility hand hygiene policies promote preferential use of alcohol-based

hand rub over soap and water except when hands are visibly soiled (e.g.,

blood, body fluids) or after caring for a resident with known or suspected C.

difficile or norovirus.

Yes | No

Hand Hygiene 2 All personnel receive training on hand hygiene at the time of employment. Yes | No

Hand Hygiene 3 All personnel receive competency validation on hand hygiene at the time of

employment.

Yes | No

Hand Hygiene 4 All personnel received training on hand hygiene within the past 12 months. Yes | No

Hand Hygiene 5 All personnel received competency validation on hand hygiene within the

past 12 months.

Yes | No

Hand Hygiene 6 The facility audits (monitors and documents) adherence to hand hygiene. Yes | No

Hand Hygiene 7 The facility provides feedback to personnel regarding their hand hygiene

performance.

Yes | No

Hand Hygiene 8 Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper

towels, alcohol-based hand rub) are readily accessible in resident care areas

(i.e., nursing units, resident rooms, therapy rooms).

Yes | No

PPE 1 The facility has a policy on Standard Precautions which includes selection

and use of PPE (e.g., indications, donning/doffing procedures).

Yes | No

PPE 2 The facility has a policy on Transmission-based Precautions that includes

the clinical conditions for which specific PPE should be used (e.g., CDI,

Influenza)

Yes | No

PPE 3 Appropriate personnel receive job-specific training on proper use of PPE at

the time of employment.

Yes | No

ICAR HAI User Guide

Page 64 of 79

LTCF Assessment

Section


applicable)

PPE 4 Appropriate personnel receive job-specific competency validation on proper

use of PPE at the time of employment.

Yes | No

PPE 5 Appropriate personnel received job-specific training on proper use of PPE

annually.

Yes | No

PPE 6 Appropriate personnel received job-specific competency validation on

proper use of PPE annually.

Yes | No

PPE 7 The facility audits (monitors and documents) adherence to PPE use (e.g.,

adherence when indicated, donning/doffing).

Yes | No

PPE 8 The facility provides feedback (and documents feedback) to personnel

regarding their PPE use.

Yes | No

PPE 9 Supplies necessary for adherence to proper PPE use (e.g., gloves, gowns,

masks) are readily accessible in resident care areas (i.e., nursing units,

therapy rooms).

Yes | No

Respiratory 1 The facility has signs posted at entrances with instructions to individuals

with symptoms of respiratory infection to cover their mouth/nose when

coughing or sneezing, use and dispose of tissues, and perform hand hygiene

after contact with respiratory secretions.

Yes | No

Respiratory 2 The facility provides resources for performing hand hygiene near the

entrance.

Yes | No

Respiratory 3 The facility provides resources for performing hand hygiene in common

areas.

Respiratory 4 The facility offers face masks to coughing residents and other symptomatic

persons upon entry to the facility.

Yes | No

Respiratory 5 The facility educates family and visitors to notify staff and take appropriate

precautions if they are having symptoms of respiratory infection during

their visit.

Yes | No

Respiratory 6 All personnel receive education on the importance of infection prevention

measures to contain respiratory secretions to prevent the spread of

respiratory pathogens.

Yes | No

ICAR HAI User Guide

Page 65 of 79

LTCF Assessment

Section


applicable)

Antibiotic Stewardship 1 The facility has leadership support for efforts to improve antibiotic use

(antibiotic stewardship).

Yes | No

Antibiotic Stewardship 2 The facility has identified individuals accountable for leading antibiotic

stewardship activities.

Yes | No

Antibiotic Stewardship 3 The facility has access to individuals with antibiotic prescribing expertise

(e.g., trained physician or pharmacist).

Yes | No

Antibiotic Stewardship 4 The facility has written policies on antibiotic prescribing. Yes | No

Antibiotic Stewardship 5 The facility has implemented practices to improve antibiotic use. Yes | No

Antibiotic Stewardship 6 The facility has a report summarizing antibiotic use from pharmacy data

created within the past 6 months. Note: Report could include number of

new starts, types of drugs prescribed, number of days of antibiotic treatment

from the pharmacy on a regular basis.

Yes | No

Antibiotic Stewardship 7 The facility has a laboratory report summarizing antibiotic resistance (i.e.,

antibiogram) created within the past 24 months.

Yes | No

Antibiotic Stewardship 8 The facility provides feedback to clinical providers with prescribing

privileges about their antibiotic prescribing practices.

Yes | No

Antibiotic Stewardship 9 The facility has provided training on antibiotic use (stewardship) to all

nursing staff within the past 12 months.

Yes | No

Antibiotic Stewardship 10 The facility has provided training on antibiotic use (stewardship) to all

clinical providers with prescribing privileges within the past 12 months.

Yes | No

Injection Safety 1 The facility has a policy on injection safety which includes protocols for

performing finger sticks and point of care testing (e.g., assisted blood

glucose monitoring, or AMBG).

Yes | No

Injection Safety 2 Personnel who perform point of care testing (e.g. assisted blood glucose

monitoring) receive training on injection safety procedures at time of

employment. Note: If point of care tests are performed by contract

personnel, facility should verify that training is provided by contracting

company.

Yes | No

ICAR HAI User Guide

Page 66 of 79

LTCF Assessment

Section


applicable)


monitoring) receive competency validation on injection safety procedures at

time of employment.

Yes | No


monitoring) received training on injection safety procedures within the past

12 months. Note: If point of care tests are performed by contract personnel,

facility should verify that training is provided by contracting company.

Yes | No


monitoring) received competency validation on injection safety procedures

within the past 12 months.

Yes | No

Injection Safety 6 The facility audits (monitors and documents) adherence to injection safety

procedures during point of care testing (e.g., assisted blood glucose

monitoring).

Yes | No

Injection Safety 7 The facility provides feedback to personnel regarding their adherence to

injection safety procedures during point of care testing (e.g., assisted blood

glucose monitoring).

Yes | No

Injection Safety 8 Supplies necessary for adherence to safe injection practices (e.g., single use,

auto-disabling lancets, sharps containers) are readily accessible in resident

care areas (i.e., nursing units).

Yes | No

Injection Safety 9 The facility has policies and procedures to track personnel access to

controlled substances to prevent narcotics theft/drug diversion.

Yes | No

Environmental 1 The facility has written cleaning/disinfection policies which include daily

and discharge cleaning and disinfection of resident rooms.

Yes | No

Environmental 2 The facility has written cleaning/disinfection policies which include daily

and discharge cleaning and disinfection of rooms for residents who are on

contact precautions (e.g. CDI)

Yes | No

Environmental 3 The facility has written cleaning/disinfection policies which include

cleaning and disinfection of high-touch / frequently-contacted surfaces in

common areas.

Yes | No

ICAR HAI User Guide

Page 67 of 79

LTCF Assessment

Section


applicable)

Environmental 4 The facility has written cleaning/disinfection policies which include

cleaning and disinfection of equipment shared among residents (e.g., blood

pressure cuffs, rehab therapy equipment, etc.).

Yes | No

Environmental 5 All medical devices (anything that comes into contact with non-intact skin

or bodily fluids) are single use only or dedicated to individual residents.

Yes | No

Environmental 6 External consultants (e.g., wound care nurses, dentists or podiatrists)

providing services which involve medical devices have adequate supplies to

ensure that no devices are shared on-site and all reprocessing is performed

off-site.

Yes | No

Environmental 7 Appropriate personnel receive job-specific training on cleaning and

disinfection procedures at the time of employment. Note: If environmental

services are performed by contract personnel, facility should verify that

training is provided by contracting company.

Yes | No

Environmental 8 Appropriate personnel receive competency validation on cleaning and

disinfection procedures at the time of employment.

Yes | No

Environmental 9 Appropriate personnel received job-specific training on cleaning and

disinfection procedures within the past 12 months.

Note: If environmental services are performed by contract personnel,

facility should verify that training is provided by contracting company.

Yes | No

Environmental 10 Appropriate personnel received competency validation on cleaning and

disinfection procedures within the past 12 months.

Yes | No

Environmental 11 The facility audits (monitors and documents) quality of all cleaning and

disinfection procedures.

Yes | No

Environmental 12 The facility provides feedback to personnel regarding the quality of all

cleaning and disinfection procedures.

Yes | No

ICAR HAI User Guide

Page 68 of 79

LTCF Assessment

Section


applicable)

Environmental 13 Supplies necessary for appropriate cleaning and disinfection procedures

(e.g., EPA-registered, including products labeled as effective against

C.difficile and Norovirus) are available.

Note: If environmental services are performed by contract personnel,

facility should verify that appropriate EPA-registered products are provided

by contracting company.

Yes | No

Outpatient Assessment Questions

Outpatient

Assessment

Section

Question # Question Answer Options (if applicable)

Facility Info 1 Rationale for Assessment (Select all that apply): Outbreak | Input from ESRD Network or state survey

agency | Participation in Infection Control and

Response (ICAR) | Recommendation of accrediting

organization or state survey agency | Increase in

healthcare-associated infections | Participation in

Prevention Collaborative | Other

Facility Info 2 If you selected "Increase in healthcare-associated

infections" above, please select infection types that have

increased. (Select all that apply)

BSI/CLABSI | MRSA | UTI/CAUTI | CDI | SSI |

Other

Facility Info 3 Is the facility licensed by the state? Yes | No

Facility Info 4 Is the facility certified by the Centers for Medicare &

Medicaid Services (CMS)?

Yes | No

Facility Info 5 Is the facility accredited? Yes | No

ICAR HAI User Guide

Page 69 of 79

Outpatient

Assessment

Section


Facility Info 5 If yes, please select the accrediting organization. (Select

all that apply)

Accreditation Association for Ambulatory Health

Care (AAAHC) | American Association for

Accreditation of Ambulatory Surgery Facilities

(AAAASF) | American Osteopathic Association

(AOA) | The Joint Commission (TJC) | Other

Facility Info 6 Which procedures are performed by the facility? Select all

that apply.

Chemotherapy | Endoscopy | Ear/Nose/Throat |

Imaging (MRI/CT) | Immunizations | OB/GYN |

Ophthalmologic | Orthopedic | Pain remediation |

Plastic/reconstructive | Podiatry | Other

Facility Info 7 What is the primary procedure-type performed by the

facility? Select one only.

Chemotherapy | Endoscopy | Ear/Nose/Throat |

Imaging (MRI/CT) | Immunizations | OB/GYN |

Ophthalmologic | Orthopedic | Pain remediation |

Plastic/reconstructive | Podiatry | Other

Facility Info 8 How many physicians work at the facility?

Facility Info 9 What is the average number of patients seen per week?

Infrastructure 1 Written infection prevention policies and procedures are

available, current, and based on evidence-based guidelines

(e.g., CDC/HICPAC), regulations, or standards. Note:

Policies and procedures should be appropriate for the

services provided by the facility and should extend beyond

OSHA bloodborne pathogen training.

Yes | No

Infrastructure 2 Infection prevention policies and procedures are re-

assessed at least annually or according to state or federal

requirements, and updated if appropriate.

Yes | No

ICAR HAI User Guide

Page 70 of 79

Outpatient

Assessment

Section


Infrastructure 3 At least one individual trained in infection prevention is

employed by or regularly available (e.g., by contract) to

manage the facility's infection control program. Note:

Examples of training may include: Successful completion

of initial and/or recertification exams developed by the

Certification Board for Infection Control & Epidemiology;

participation in infection control courses organized by the

state or recognized professional societies (e.g., APIC,

SHEA).

Yes | No

Infrastructure 4 Facility has system for early detection and management of

potentially infectious persons at initial points of patient

encounter.

Yes | No

Infrastructure 5 Facility has a competency-based training program (i.e.,

correct technique observed by a trainer) that provides job-

specific training on infection prevention policies and

procedures to healthcare personnel. Note: This includes

those employed by outside agencies and available by

contract or on a volunteer basis to the facility.

Yes | No

HCP Safety 1 Facility has an exposure control plan that is tailored to the

specific requirements of the facility (e.g., addresses

potential hazards posed by specific services provided by

the facility). Note: A model template, which includes a

guide for creating an exposure control plan that meets the

requirements of the OSHA Bloodborne Pathogens

Standard is available at:

https://www.osha.gov/Publications/osha3186.pdf.

Yes | No

HCP Safety 2 HCP for whom contact with blood or other potentially

infectious material is anticipated are trained on the OSHA

bloodborne pathogen standard upon hire.

Yes | No

ICAR HAI User Guide

Page 71 of 79

Outpatient

Assessment

Section


HCP Safety 3 HCP for whom contact with blood or other potentially

infectious material is anticipated are trained on the OSHA

bloodborne pathogen standard at least annually.

Yes | No

HCP Safety 4 Following an exposure event, post-exposure evaluation

and follow-up, including prophylaxis as appropriate, are

available at no cost to employee and are supervised by a

licensed healthcare professional. Note: An exposure

incident refers to a specific eye, mouth, other mucous

membrane, non-intact skin, or parenteral contact with

blood or other potentially infectious materials that results

from the performance of an individual's duties.

Yes | No

HCP Safety 5 Facility tracks HCP exposure events and evaluates event

data and develops/implements corrective action plans to

reduce incidence of such events.

Yes | No

HCP Safety 6 Facility follows recommendations of the Advisory

Committee on Immunization Practices (ACIP) for

immunization of HCP, including offering Hepatitis B and

influenza vaccination. Note: Immunization of Health-Care

Personnel: Recommendations of the ACIP available at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.

htm.

Yes | No

HCP Safety 7 All HCP receive baseline tuberculosis (TB) screening

prior to placement, and those with potential for ongoing

exposure to TB receive periodic screening (if negative) at

least annually.

Yes | No

HCP Safety 8 If respirators are used, the facility has a respiratory

protection program that details required worksite-specific

procedures and elements for required respirator use,

including provision of medical clearance, training, and fit

testing as appropriate.


ICAR HAI User Guide

Page 72 of 79

Outpatient

Assessment

Section


HCP Safety 9 Facility has well-defined policies concerning contact of

personnel with patients when personnel have potentially

transmissible conditions.

Yes | No

HCP Safety 9a Work-exclusion policies that encourage reporting of

illnesses and do not penalize with loss of wages, benefits,

or job status.

Yes | No

HCP Safety 9b Education of personnel on prompt reporting of illness to

supervisor.

Yes | No

Surveillance 1 All personnel can access an updated list of diseases

reportable to the public health authority.

Yes | No

Surveillance 2 Facility complies with mandatory reporting requirements

for notifiable diseases, healthcare associated infections (as

appropriate), and for potential outbreaks.

Yes | No

Surveillance 3 Patients who have undergone procedures at the facility are

educated regarding signs and symptoms of infection that

may be associated with the procedure and instructed to

notify the facility if such signs or symptoms occur.

Yes | No

Hand

Hygiene

1 All HCP are educated regarding appropriate indications

for hand hygiene upon hire, prior to provision of care:

Yes | No

Hand

Hygiene

2 All HCP are educated regarding appropriate indications

for hand hygiene at least annually.

Yes | No

Hand

Hygiene

3 HCP are required to demonstrate competency with hand

hygiene (i.e., correct technique observed by a trainer)


Yes | No

Hand

Hygiene

4 Facility regularly audits adherence to hand hygiene (i.e.,

systematically collects and monitors data).

Yes | No

Hand

Hygiene

5 Facility provides feedback from audits to personnel

regarding their hand hygiene performance.

Yes | No

ICAR HAI User Guide

Page 73 of 79

Outpatient

Assessment

Section


Hand

Hygiene

6 Hand hygiene policies promote preferential use of alcohol-

based hand rub over soap and water in all clinical

situations except when hands are visibly soiled (e.g.,

blood, body fluids) or after caring for a patient with known

or suspected C. difficile or norovirus.

Yes | No

PPE 1 HCP who use PPE receive training on proper selection and

use of PPE upon hire, prior to provision of care.

Yes | No


use of PPE at least annually.

Yes | No


use of PPE when new equipment or protocols are

introduced.

Yes | No

PPE 4 HCP are required to demonstrate competency (i.e., correct

technique observed by a trainer) with selection and use of

PPE following each training.

Yes | No

PPE 5 Facility regularly audits adherence to proper PPE selection

and use (i.e., systematically collects and monitors data).

Yes | No

PPE 6 Facility provides feedback from audits to personnel

regarding their performance with selection and use of PPE.

Yes | No

Injection

Safety

1 HCP who prepare and/or administer parenteral

medications receive training on safe injection practices

upon hire, prior to being allowed to prepare and/or

administer parenteral medications.

Yes | No

Injection

Safety


medications receive training on safe injection practices at

least annually.

Yes | No

Injection

Safety


medications receive training on safe injection practices

when new equipment or protocols are introduced.

Yes | No

ICAR HAI User Guide

Page 74 of 79

Outpatient

Assessment

Section


Injection

Safety

4 HCP are required to demonstrate competency with safe

injection practices (i.e., correct technique observed by a

trainer) following each training.

Yes | No

Injection

Safety

5 Facility regularly audits adherence to safe injection

practices (i.e., systematically collects and monitors data).

Yes | No

Injection

Safety


regarding their adherence to safe injection practices.

Yes | No

Injection

Safety

7 Facility has policies and procedures to track HCP access to

controlled substances to prevent narcotics theft/diversion.

Note: Policies and procedures should address: how data

are reviewed, how facility would respond to unusual

access patterns, how facility would assess risk to patients

if tampering (alteration or substitution) is suspected or

identified, and to contact public health if diversion is

suspected or identified.

Yes | No

Respiratory 1 Facility has policies and procedures to contain respiratory

secretions in persons who have signs and symptoms of a

respiratory infection, beginning at point of entry to the

facility and continuing through the duration of the visit.

Note: If available, facilities may wish to place patients

with symptoms of a respiratory infection in a separate area

while waiting for care.

Yes | No

Respiratory 1a Policies include: Offering face masks to coughing patients

and other symptomatic persons upon entry to the facility,

at a minimum, during periods of increased respiratory

infection activity in the community.

Yes | No

Respiratory 1b Policies include: Providing space in waiting rooms and

encouraging persons with symptoms of respiratory

infections to sit as far away from others as possible.

Yes | No

ICAR HAI User Guide

Page 75 of 79

Outpatient

Assessment

Section


Respiratory 2 Facility educates HCP on the importance of infection

prevention measures to contain respiratory secretions to

prevent the spread of respiratory pathogens.

Yes | No

Point-of-Care

Testing

(POC)

N/A Does your facility perform point-of-care testing?

(If answer is no, POC section is complete)

Yes | No

Point-of-Care

Testing

(POC)

1 HCP who perform point-of-care testing receive training on

recommended practices upon hire, prior to being allowed

to perform point-of-care testing.

Yes | No

Point-of-Care

Testing

(POC)


recommended practices at least annually.

Yes | No

Point-of-Care

Testing

(POC)


recommended practices when new equipment or protocols

are introduced.

Yes | No

Point-of-Care

Testing

(POC)

4 HCP are required to demonstrate competency (i.e., correct

technique observed by a trainer) with recommended

practices for point-of-care testing following each training.

Yes | No

Point-of-Care

Testing

(POC)

5 Facility regularly audits adherence to recommended

practices during point-of-care testing (i.e., systematically

collects and monitors data).

Yes | No

Point-of-Care

Testing

(POC)


regarding their adherence to recommended practices.

Yes | No

Environment

al

1 Facility has written policies and procedures for routine

cleaning and disinfection of environmental surfaces,

including identification of responsible personnel.

Yes | No

ICAR HAI User Guide

Page 76 of 79

Outpatient

Assessment

Section


Environment

al

2 Personnel who clean and disinfect patient care areas (e.g.,

environmental services, technicians, nurses) receive

training on cleaning procedures upon hire, prior to being

allowed to perform environmental cleaning. Note: If

environmental cleaning is performed by contract

personnel, facility should verify this is provided by

contracting company.

Yes | No

Environment

al



training on cleaning procedures at least annually. Note: If

environmental cleaning is performed by contract

personnel, facility should verify this is provided by

contracting company.

Yes | No

Environment

al



training on cleaning procedures when new equipment or

protocols are introduced. Note: If environmental cleaning

is performed by contract personnel, facility should verify


Yes | No

Environment

al

5 HCP are required to demonstrate competency with

environmental cleaning procedures (i.e., correct technique

observed by a trainer) following each training.

Yes | No

Environment

al

6 Facility regularly audits adherence to cleaning and

disinfection procedures (i.e., systematically collects and

monitors data), including using products in accordance

with manufacturer's instructions (e.g., dilution, storage,

shelf-life, contact time).

Yes | No

Environment

al


regarding their adherence to cleaning and disinfection

procedures.

Yes | No

ICAR HAI User Guide

Page 77 of 79

Outpatient

Assessment

Section


Environment

al

8 Facility has a policy/procedure for decontamination of

spills of blood or other body fluids.

Yes | No

Environment

al - Operating

Room

N/A This facility has an operating room:

(If answer is no, Environmental – OR section is complete)

Yes | No

Environment

al - Operating

Room

1 Operating rooms are terminally cleaned after last

procedure of the day.

Yes | No

Environment

al - Operating

Room

2 Facility regularly audits adherence (i.e., systematically

collects and monitors data) to preoperative surgical scrub

and hand hygiene.

Yes | No

Environment

al - Operating

Room


collects and monitors data) to appropriate use of surgical

attire and drapes.

Yes | No

Environment

al - Operating

Room


collects and monitors data) to aseptic technique and sterile

field.

Yes | No

Environment

al - Operating

Room


collects and monitors data) to proper ventilation

requirements in surgical suites.

Yes | No

Environment

al - Operating

Room


collects and monitors data) to minimization of traffic in

the operating room.

Yes | No

Environment

al - Operating

Room


collects and monitors data) to cleaning and disinfection of

environmental surfaces.

Yes | No

Environment

al - Operating

Room


regarding their adherence to surgical infection prevention

practices.

Yes | No

ICAR HAI User Guide

Page 78 of 79

Outpatient

Assessment

Section


Device

Reprocessing

1 Facility has policies and procedures to ensure that reusable

medical devices are cleaned and reprocessed appropriately

prior to use on another patient. Note: This includes clear

delineation of responsibility among HCP for cleaning and

disinfection of equipment including, non-critical

equipment, mobile devices, and other electronics (e.g.,

point-of-care devices) that might not be reprocessed in a

centralized reprocessing area.

Yes | No

Device

Reprocessing

2 The individual(s) in charge of infection prevention at the

facility is consulted whenever new devices or products

will be purchased or introduced to ensure implementation

of appropriate reprocessing policies and procedures.

Yes | No

Device

Reprocessing

3 HCP responsible for reprocessing reusable medical

devices receive hands-on training on proper selection and

use of PPE and recommended steps for reprocessing

assigned devices upon hire, prior to being allowed to

reprocess devices. Note: If device reprocessing is

performed by contract personnel, facility should verify this

is provided by contracting company.

Yes | No

Device

Reprocessing




assigned devices at least annually. Note: If device

reprocessing is performed by contract personnel, facility

should verify this is provided by contracting company.

Yes | No

ICAR HAI User Guide

Page 79 of 79

Outpatient

Assessment

Section


Device

Reprocessing




assigned devices when new devices are introduced or

policies/procedures change. Note: If device reprocessing is

performed by contract personnel, facility should verify this

is provided by contracting company.

Yes | No

Device

Reprocessing

6 HCP are required to demonstrate competency with

reprocessing procedures (i.e., correct technique is

observed by trainer) following each training.

Yes | No

Device

Reprocessing

7 Facility regularly audits adherence to reprocessing

procedures (i.e., systematically collects and monitors

data).

Yes | No

Device

Reprocessing


regarding their adherence to reprocessing procedures.

Yes | No

Device

Reprocessing

9 Facility has protocols to ensure that HCP can readily

identify devices that have been properly reprocessed and

are ready for patient use (e.g., tagging system, storage in

designated area).

Yes | No

Device

Reprocessing

10 Facility has policies and procedures outlining facility

response (i.e., risk assessment and recall of device) in the

event of a reprocessing error or failure.

Yes | No

Device

Reprocessing

Environment

al - Operating

Room

Routine maintenance for reprocessing equipment (e.g.,

automated endoscope reprocessors, steam autoclave) is

performed by qualified personnel in accordance with

manufacturer instructions.


Documents

INFECTION CONTROL ASSESSMENT AND RESPONSE USER …