The Facility Infection Preventionist (IP) in conjunction with the Inservice Coordinator/Designee, must provide education on Infection Prevention and Management upon the hiring of new staff, as well as ongoing education on an annual basis and as needed should a facility experience the outbreak of an infectious disease.  


Elements of Infection Prevention Training are provided during orientation, mandatory training, and job-specific competency

These elements include:

  1. Reporting:  When and to whom possible incidents of communicable disease or infections should be reported. It is the policy that the facility will follow State reporting requirements on which communicable diseases will be reported to the local/state authorities
  2. Standard and transmission-based precautions to be followed to prevent the spread of infections.
    1. Hand Hygiene to be followed by staff with direct care, handling resident care equipment and the environment
    2. Selection and Use of PPE
    3. Provision of facemasks for residents with new respiratory symptoms
  3. When and how isolation should be used for a resident; including but not limited to;
    1. The type and duration of the isolation, depending upon the infectious agent or organism involved.
    2. A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
    3. Selection of room (private/semi-private/cohorted) on a case-by-case basis as appropriate and available-facility to identify risk factors that could lead to the likelihood of transmission
      1. Identification of process to manage a resident when a private room is not available
      2. Limiting the movement of a resident with a highly infectious disease for only medically necessary purposes
  4. Implementation of Respiratory Hygiene/Cough Etiquette
    1. Resources and instructions provided at the lobby
      1. Dispenser for Alcohol-based hand rub
      2. During times of increased prevalence of respiratory infections in the community, facemasks will also be available. 
  5. Occupational Health procedures, including:
    1. The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food if direct contact transmits the disease.
    2. The facility Exposure Control Plan
    3. Education and competency assessment
  6. The hand hygiene procedures to be followed by staff involved in direct resident contact.
  7. Resident Care Activity procedures including
    1. Use and care of urinary catheters consistent with requirements and best practice
    2. Wound care, incontinence care, and skincare
    3. Fingerstick and point-of-care testing
    4. Preparation, administration, and care for medications administered by injection or peripheral and central venous catheters
    5. Use and care of peripheral and central venous catheters
  8. Environmental cleaning and disinfection
    1. Routine Cleaning and disinfection
    2. Cleaning/disinfection of resident care equipment, including shared equipment
The facility will designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The infection preventionist will:
  • Have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field; 
  • Is qualified by education, training, experience or certification.
  • Works at least part-time at the facility.
  • Has completed specialized training in infection prevention and control.
  • Be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis
  • Be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
  1. Policies and Procedures for the facility Influenza and Pneumococcal Immunizations
  2. See Infection Control Manual for details




Infection Preventionist / RN Supervisor1. Conduct annual competency-based education on hand hygiene and donning/doffing Personal Protective Equipment (PPE) for staff.
2. Provide in-service training for all staff on Infection Prevention policies and procedures as needed for event of an infectious outbreak including all CDC and State updates/guidance.
3. Guide Departments as to the job specific training that is required for each discipline