Infection Preventionist

License/Certification:

• RN or LPN (Required)

Position Description and Purpose:

The Infection Preventionist is a key person on the Infection prevention team and in most cases is designated as the person having responsibility for the Infection Prevention and Control program. The Infection Preventionist is responsible for dissemination of infection prevention information, including surveillance data and policy decisions. The Infection Preventionist comes from a nursing background but may come from other disciplines including but not limited to medical technology, microbiology, epidemiology, or other related field. The Infection Preventionist has a working familiarity of the position description and will make recommendations to the Administrator and the facility’s Quality Assurance and Performance Improvement team for revisions as the position responsibilities and information evolves.

The Infection Preventionist is responsible for the effective direction, management and operation of the infection prevention program including education of facility staff members and independent practitioners and consulting with County and State Department of Health and Environment. The Infection Preventionist utilizes evidence-based practices such as those published by the Centers for Disease Control (CDC). Additionally, the Infection Preventionist ensures compliance with regulations and requirements from the Centers for Medicare and Medicaid Services (CMS) and other accrediting healthcare organizations and State regulatory agencies.

The Infection Preventionist is responsible for the facility’s activities aimed at preventing healthcare-associated infections (HAIs) by ensuring that sources of infections are isolated to limit the spread of infectious organisms. The Infection Preventionist systematically collects, analyzes and interprets health data in order to plan, implement, evaluate, and disseminate appropriate public health practices. The Infection Preventionist conducts educational and training activities for facility staff members through instruction and dissemination of information on healthcare practices.

Delegation of Authority

The Infection Preventionist is delegated the administrative authority and accountability necessary for carrying out any and all assigned duties which are consistent with the scope of practice including but not limited to the Nurse Practice Act of the State of Kansas Board of Nursing or the licensing or credentialing board of the person assigned to this position.

Supervision:

The Infection Preventionist is under the direct supervision of the facility’s Director of Nursing and/or the Administrator.

Qualifications and Position Requirements:

• Must possess current, unencumbered, active licensure in an applied clinical science including but not limited to: Nursing, Medical Technology, Microbiology, Epidemiology, or other related field or other appropriate educational degree
• Must possess current professional licensure in State if appropriate to primary discipline
• Must work in the facility for substantial time to complete with Infection Prevention duties
• Must possess current, specialized training and certification in Infection Control (CIC) in approved course
• Must participate in the facility’s Quality Assurance Performance Improvement (QAPI) Committee and report on a regular basis
• Must possess previous experience in teaching, curriculum development, and instruction is desired
• Must provide documentation of attendance at face-to-face and/or completion of educational offerings
• Must possess excellent leadership skills
• Must respect for principles of resident rights, confidentiality, EEO, and ADA
• Must possess ability to read, write, speak, and understand the English language
• Must possess proficiency in computer and software skills
• Must possess ability to write reports and other forms of correspondence
• Must possess ability to present verbal and/or written information and respond to the most sensitive inquiries or complaints
• Must possess ability to apply mathematical concepts such as fractions, percentages, rates and proportions to practical situations
• Must possess ability to work with mathematical concepts such as probability and statistical tools for analysis and problem solving
• Must possess ability to create and interpret various charges and graphs to present in an understandable format
• Must possess ability to reason, define problems, collect data, establish facts, and draw conclusions
• Must possess ability to interpret instructions furnished in written, oral, schematic, and schedule form
• Must possess ability to apply principles of logical and/or scientific thinking to a wide range of intellectual and practical problems
• Must possess ability to interpret nonverbal symbolism (formulas, scientific equations, graphs)
• Must possess ability to use information management systems for:
  • Data entry and retrieval
  • Data collection and organization
  • Data analysis and evaluation
  • Required reporting
  • Integration of diverse sources of data
• Must possess ability to interpret State Health Standards, CMS Condition of Participation, Health Insurance Portability and Accountability Act (HIPAA) standards, information on CDC website, and medical/legal concepts related to healthcare data
• Must possess ability to complete data entry into the National Health Safety Network (NHSN) in a timely basis
• Must possess the ability to apply knowledge and skills related to quality improvement tools and techniques, including statistical process control
• Must possess the ability to make independent decisions when circumstances warrant such action
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care
• Must possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices
• Must be able to relate information concerning an resident’s condition
• Must not pose a direct threat to the health or safety of other individuals in the workplace

Other Training, Skills and Experience Recommendations:

• Computer skills, knowledge of medical terminology, dementia training
• On-the-job training and on-going education will be provided

Responsibilities:

• Implements and reviews facility’s Infection Prevention Program
• Ensures that existing standards and guidelines of applicable professional organizations and regulatory and governmental agencies are incorporated into the program
• Reviews relevant public health issues to integrate into practice
• Serves as a consultant and resource person related to infection prevention issues for all facility personnel
• Collaborates with other healthcare professionals within and outside the facility
• Implements infection prevention education programs
• Systematically collects and analyzes healthcare-associated infection data using epidemiological principles and statistical methods to identify trends and risk factors
• Responsible to perform reporting of HAI and quality data to various local, County, State, and Federal reporting requirements
• Ensure the principles of Antibiotic Stewardship are consistently and appropriately educated and followed including education and practice with local practitioners and physician extenders, facility staff members, residents and family members
• Incorporates the principles of fiscal responsibility into practice and promotes the standards of advanced professional practice
• Actively participates in the facility’s Quality Assurance and Performance Improvement Program
• Establishes, implements and administers infection prevention program goals, objectives, policies and procedures
• Conducts ongoing review of facility policies, procedures, and guidelines to identify infection prevention discrepancies and implements revisions as necessary
• Ensures that the infection prevention program goals are compatible with and enhance the facility’s mission, vision, values and strategic plan
• Provides information to facility committees and department managers to formulate changes in the policies, procedures, and/or processes which could reduce the spread of infection
• Interacts with medical and nursing staff, department managers, supervisors, and employee health employees and other professional/non-professional staff members to provide resource information, resolve infection prevention and control issues, and identify new opportunities to improve services and reduce cost
• Works with department managers to apply effective polices and procedures for the departments and facility that ensures compliance with OSHA, CDC, CMS and other Local, County, State, and Federal regulatory and/or accrediting agencies
• Develops reports and statistical data for the IPC, medical staff, Medical Director, and the facility’s administration as well as other committees as needed
• Develops and coordinates the Infection Prevention program throughout the facility
• Implements the program by formulating, establishing and evaluating policies and procedures related to resident care infection prevention measures throughout the facility
• Performs an annual risk assessment and develops action plans from the prior year’s activities which may include development of a dashboard to maintain monthly data
• Makes recommendations related to construction and renovation projects and participation in all Infection Control Risk Assessment activities and environmental rounds including assuring compliance with national and/or professional standards
• Works with employee health in monitoring work-related exposures
• Develops and updates the Blood-Borne Pathogens Exposure Control Plan
• Reviews the components of the facility’s infection prevention and control program to include:
  • Policies and procedures
  • Program oversight
  • Surveillance activities
    • Process surveillance
    • Outcome surveillance
  • Antibiotics included in facility’s formulary
  • Antibiogram review of facility’s resistant pattern over time
  • Laboratory processes including the minimum inhibitory concentration
• Conducts outbreak investigations which includes knowing what constitutes an outbreak
• Reviews the State’s Department of Health’s Reportable Disease and Conditions requirements and ensures those requirements are met
• Documentation and Reporting
  • On a monthly basis, the Infection Preventionist will:
    • Update a log of all HAIs
    • Review all laboratory results including Multi-drug-resistant-organisms (MDRO)
    • Data entry into NHSN reporting system according to facility’s reporting plan
      • Surgical site infections
      • MDROs
      • CAUTI (Catheter-Associated Urinary Tract Infection)
      • Clostridium difficile infection (facility-wide)
      • CLABSI (Central Line-Associated Blood Stream Infection)
    • Data entry into NHSH reporting system related to employee influenza vaccination status
    • Compliance with hand hygiene and precaution policies including review with clinical department managers
    • Ensure all communicable diseases are reported to appropriate County and State health department personnel
    • Report all pertinent data to assigned committees
    • Review national data for HAIs, review facility’s data and develop goals for reduction of HAIs
    • Ensure all residents admitted to facility have been presented the opportunity to receive or refuse to receive current Influenza and Pneumococcal immunizations
    • Ensure all current residents of facility receive ongoing immunizations as recommended by CDC
    • Log and track all immunization data and present to ICC and QAPI team
    • Data analysis of:
      • Number of infection per residents at risk
      • Frequency of infections over time
      • HAI rates and graphs from data output in NHSN
    • Develops strategies regarding program development/implementation and how IP oversight will emphasize prevention and management of HAIs
    • Reviews facility’s tuberculosis screening program, management of exposure and ensures follow up on cases consistent with State requirements
    • Reviews food safety policies and procedures in conjunction with dietary manager
    • Reviews facility’s pest control program
    • Reviews facility’s hazardous waste disposal program
  
  

Essential Functions (with or without reasonable accommodations):

The duties and responsibilities included under the essential functions listing have been determined by management to be essential to the successful performance of this position. However, this listing may not be inclusive of all the duties and responsibilities that may be required. The omission or exclusion of duties and responsibilities from this description does not infer that the designated employee will not be required to perform additional job-specific duties if the work is similar, related or becomes an essential function of this position.

• Conducts rounds on a daily basis and performs and documents random audits of compliance with all Infection Prevention and Control policies and procedures
• Discusses and monitors infection prevention practices with staff members
• Collects infection data from departments
• Maintains records for each case of healthcare-associated infection
• Conducts outbreak investigation
• Trains staff members on implementation of infection prevention practices
• Investigates incidents of infections
• Reports incidents to appropriate person/department
• Ensures availability of supplies required for infection prevention activities
• Makes recommendations related to prevention and control of infection on a 24-hour basis
• Provides advice for all staff members related to management of infectious resident and other infection prevention issues
• Coordinates annual infection control risk assessment in conjunction with the Infection Prevention Committee (IPC)
• Develops and implements annual infection prevention plan in conjunction with the Infection Control Committee
• Evaluates the annual plan for goal achievement in injunction with the IPC
• Evaluates the annual plan for goal achievement in conjunction with the IPC
• Conducts surveillance of infections
• Ensures the completion of audits related to the implementation of and compliance with selected policies
• Provides education and training and ensure competencies for all staff members and independent practitioners related to Infection Prevention and Control and Antibiotic Stewardship
• Acts as or coordinates with the Employee Health Nurse related to relevant staff member health issues
• Liaise with clinical teams related to the development of standards, audits, and research in the facility
• Presents and/or provides the infection control annual report to the IPC and the QAPI Steering Committee, the CEO/Administrator and Board of Governance
  • Report to include results of infection prevention program goal achievements and matters of concern
• Cooperates with County, State, and Federal authorities related to infectious and communicable disease reporting

Physical Requirements and Emotional Requirements:

The employee must be able:

• To move intermittently throughout the workday
• Speak and write the English language in an understandable manner
• Able to cope with mental and emotional stress of position
• Able to see & hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of the position can be fully met
• Function independently and have flexibility, personal integrity, and ability to work effectively with elders, family members, personnel and support agencies
• Be in good general health and demonstrate emotional stability
• Able to relate to and work with ill, disabled, emotionally upset and at times, hostile people within the facility
• Able to assist in evacuation of elders during emergency situations
• See, hear or use prosthetic devices to enable use of the senses adequately
• Assist with the evacuation of elders if necessary
• Sits, stand, bend, stoop lifts & moves for extended periods of time
• Dexterity of hands and fingers to operate equipment
• Subject to frequent interruptions
• Ability to lift, move, push or pull a minimum of fifty (50) pounds
• Involved with elders, personnel, visitors, government agencies/personnel under all conditions and circumstances
• Subject to hostile and emotionally upset elders, family members, personnel and visitors
• Communicates with medical staff, nursing personnel and other department supervisors
• Works beyond normal working hours and in other positions temporarily when necessary

Work Environment:

• The primary work environment is throughout the facility and at times the work is stressful
• The employee may be exposed to blood, body fluids, infectious diseases and air contaminants
• The employee may be subject to work call-back during times of facility emergency or disaster preparedness functions
• Employee must be organized and detail-oriented
• Employee may be requested to perform other duties or tasks that are not listed, but are within the competence and training of the individual.

Summary of Occupational Exposures:

Bloodborne Pathogens:

Tasks and procedures performed by employee involve risks classified by CDC as: Category III (Task/activity does not entail predictable or unpredictable exposure to blood.)

Specific Task Exposure:

• General Resident Care: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions other body fluids-cerebrospinal, synovial, pleural, peritoneal, pericardial
• Handling soiled linens and clothing: Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions, other body fluids-cerebrospinal, synovial, pleural, peritoneal, pericardial
• Cleaning resident rooms and common areas-Blood, urine, feces, vomitus, wound exudates, semen/vaginal secretions
• Refer to Exposure Control Plan for additional information

Benefits:

Health and vision care, dental and PTO

About Us:

Enterprise Estate Nursing Center is a community owned, non-profit nursing facility committed to providing personalized service with the highest standard of care since 1975. The resident rooms at Enterprise Estates offer a full range of service while our goal is to always serve our senior community with dignity and respect. Residents enjoy a safe, caring, homelike setting in a clean and inspiring environment.