CMS Pub. 100-11, ch. 7, § 20.9

The PACE organization must establish, implement, and maintain a documented infection

control plan that ensures a safe and sanitary environment and prevents and controls the

transmission of disease and infection. An infection control plan must include, but is not

limited to: (1) procedures to identify, investigate, control, and prevent infections in every

PACE center and in each participant’s place of residence; (2) procedures to record any

incidents of infection; and (3) procedures to analyze the incidents of infection, to identify

trends and develop corrective actions related to the reduction of future incidents. PACE

organizations are required to follow accepted policies and standard procedures with

respect to infection control, including, at the least, the standard precautions developed by

the Center for Disease Control and Prevention (CDC).

PACE organizations are expected to establish written policies and procedures for the

investigation, control, and prevention of infections including:

• An OSHA Exposure Control Plan which includes the Universal Precautions and

Bloodborne Pathogen exposure procedures for staff;

• Vaccinating participants and staff against diseases of particular concern for the

PACE participant and the center’s geographic location, e.g., influenza and

pneumonia;

• Initial and ongoing health screening and vaccinations for staff and participants in

accordance with OSHA regulations (staff) and CDC guidelines for tuberculosis,

Hepatitis B and other communicable diseases;

• Written plans and procedures for the investigation, evaluation, resolution, and

reporting of all incidences of staff and participant infection;

• Written plans and procedures for maintaining records of staff and participant

infections to include post-exposure evaluation, training records, and participant

and staff surveillance reports. Written plans and procedures for reporting required

communicable diseases to the appropriate state and local officials;

• Plans and procedures for staff providing direct care to patients with infection(s);

• Provision of adequate facilities and supplies necessary for infection control to

include:

ο Hand washing facilities and supplies;

ο Laundry facilities and supplies;

ο Isolation facilities and supplies;

• Written plans and procedures for addressing how laundry will be handled. If the

service is contracted out, written agreements to comply with the requirements;

• Written plans and procedures for the ongoing monitoring of the contractual

agreement provisions for laundry and waste disposal;

• Written plans and procedures for the appropriate handling and disposal of all

waste products including blood and urine specimens for outside lab tests and other

biohazardous wastes.

The CDC Guidelines for Environmental Infection Control in Health Care Facilities can

be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm. The OSHA

Guidelines for the handling of laundry and labeling of bio-hazardous waste can be found

at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&

p_id=10051#1910.1030(d)(4)(iv) . Should the State requirements be more stringent than

those listed above, it is expected that the PACE organization will follow those

requirements. Check with the State Administering Agency for the Guidelines for

Environmental Infection Control in Health Care Facilities established by the State in

which the PACE organization resides.

[42 CFR § 460.74]