CMS SOM App. B, Tag G684

The HHA must maintain a coordinated agency-wide program for the surveillance,

identification, prevention, control, and investigation of infectious and communicable

diseases that is an integral part of the HHA’s quality assessment and performance

improvement (QAPI) program. The infection control program must include:

Interpretive Guidelines §484.70(b)

The HHA should have a program for the surveillance, identification, prevention, control

and investigation of infectious and communicable diseases specific to care and services

provided in the home setting. The CDC defines surveillance as “the ongoing, systematic

collection, analysis, interpretation and evaluation of health data closely integrated with

the timely dissemination of this data to those who need it.”

As part of its infection control program the HHA should: (1) observe and evaluate

services from all disciplines to identify sources or causative factors of infection, track

patterns and trends of infections; and (2) establish a corrective plan for infection control

(if appropriate) and monitor the effectiveness of the corrective plan. Cross Reference to

§484.65(a), QAPI Program Scope.

§484.70(b)(1) A method for identifying infectious and communicable disease

problems; and

Interpretive Guidelines §484.70(b)(1)

The HHA must develop a procedure for the identification of infections or risk of

infections among patients. It is the prerogative of the HHA to determine the methodology

to be used for such identification. Example methodologies include, but are not limited to:

• Clinical record review;

• Staff reporting procedures;

• Review of laboratory results;

• Data analysis of physician or allowed practitioner and emergency room visits

for symptoms of infection; and

• Identification of root cause of infection through evaluation of HHA personnel

technique and self-care technique by patients or caregivers.

Analysis of surveillance data should be used to improve care practices and control

infections and transmission of communicable diseases.

While not required by the regulation, CMS suggests HHAs have a way to receive alerts

from the CDC Health Alert Network

or local public health network as a means of staying

up to date with alerts and information related to public health incidents (as seen with the

2019 Novel Coronavirus public health emergency).

§484.70(b)(2) A plan for the appropriate actions that are expected to result in

improvement and disease prevention.

Interpretive Guidelines §484.70(b)(2)

The HHA must develop an action plan to address or prevent infections or transmission of

communicable diseases. Such plan should be based on surveillance findings, any

identified root cause of infection or disease transmission, tracking data and analysis of

data findings.

Actions to facilitate improvements and disease prevention may include the following:

• Policy, procedure or practice changes to improve care;

• Education for patients, caregivers, and HHA personnel to prevent infections and

transmission of communicable diseases; and

• The development of process or outcome measures which could be used to monitor and

address identified issues (e.g., infection prevention and control observations for

technique).

The HHA must evaluate and revise the plan as needed.