Infection Prevention Must Take Center Stage for Nursing Homes — But Operators Face Logistical, Financial Hurdles

One of the scarcest resources in any workplace setting is time, and for nursing homes, one of the casualties of this scarce resource tends to be the position of infection preventionist.

This usually takes the form of adding the duties of an IP to an already existing role in the nursing home workplace, and in the time of COVID-19, this had severe consequences for residents and staff, according to the Association for Professionals in Infection Control and Epidemiology (APIC).

After New York attorney general Letitia James released a report in January suggesting that COVID-19 deaths in the state’s nursing homes may have been undercounted by as much as 50% — a toll exacerbated by an inadequate staffing model — APIC issued a call for nursing homes in New York to make improvements.


Specifically, the association indicated that nursing homes should:

  • Require a minimum of one full-time certified infection preventionist in each nursing home
  • Ensure that infection prevention personnel in nursing homes are trained and certified in their field of expertise
  • Require health departments to collect and publicly report data on infection rates and the number of certified infection preventionists in nursing homes

But the calls for infection prevention improvements go beyond New York, and the pandemic highlights the need for changes in how nursing homes look at the position of IP, APIC argued. It’s an argument echoed by others, particularly advocacy groups for residents and families, who have cited poor compliance with infection prevention as one of the factors in the severity of COVID-19’s impact in nursing homes.

“It all goes back to long-term care staffing opportunities, and the way that historically infection prevention has been looked at, as far as resources,” Connie Steed, immediate past president of APIC, told Skilled Nursing News in a February 24 interview. “Now nursing homes for years have had infection control standards and regulations. What’s been missing is sufficient resources — in other words, an IP — to actually staff it.”


For many nursing homes, they have perhaps half of a full-time equivalent (FTE) in this position, she argued, but more is needed in long-term care: specifically a full-time, dedicated, trained IP.

Nursing homes are required by law to designate an individual as an infection preventionist, “for whom the infection prevention and control program (IPCP) is a major responsibility,” according to the final rule reforming requirements for long-term care facilities that was finalized in October 2016.

“We have revised the requirement to specify that each facility may designate more than one person as the IP and the IPCP no longer has to be a major responsibility of the individual(s),” the rule said. “The IP is responsible for assessing the current program, making any changes to the IPCP necessary to comply with the program’s requirements, and implementing and managing the IPCP … The percentage of a full-time equivalent position (FTE) that will be required at each facility will vary greatly.”

But in the health care setting, the role itself is critical, no matter what the size. For the Rev. Dr. Derrick DeWitt Sr., the director and chief financial officer at the Maryland Baptist Aged Home, the importance of infection prevention was so obvious that he made it the cornerstone of his efforts to turn the nursing home around financially — the reason he was sent to oversee the facility in the first place.

For him, it was an obvious focus, given the home’s small size; it has 30 residents and 42 full- and part-time employees.

“When I was sent over to the nursing home to try to figure out what the problems were, if there’s one thing that’s going to sink a small facility like ours, it’s going to be widespread infection,” he told SNN. “So that became one of the priorities.”

DeWitt was sent to oversee the home close to a decade ago, and he made infection a priority by hiring a full-time infection control and quality assurance nurse at the time of that appointment. But it came at a cost both in terms of criticism and in terms of finances.

Specifically, DeWitt had to take a pay cut of roughly $20,000 for about five years, one for every year the infection control nurse was full-time.

And though Maryland Baptist Aged Home was able to build a solid foundation of infection protocols from that hire — enough that now the infection control nurse’s presence is part-time three days a week after about eight years of keeping the position full-time — DeWitt emphasized that the decision to make it full-time those years ago was a difficult pitch for both the board and for others he spoke with in the SNF industry.

“The criticism was that normally, for facility as small as ours, we wouldn’t have quality assurance and infection control nurse as a full time staff member,” he told SNN. “Normally, that would be somebody who comes in maybe a couple days a week, or would be an extra duty for one of the nurses that you already have on staff. But in my estimation, it was very critical for us.”

While proper infection control was always an important part of nursing home safety even before COVID-19, the pandemic illustrated a clear payoff for DeWitt’s insistence: The facility has become nationally known for its success at keeping the virus out of the building, putting Maryland Baptist Aged Home’s practices in the spotlight.

Determining ‘sufficient time’

When COVID-19 began to make its impact felt in the U.S., starting with a major outbreak in a nursing home in the state of Washington, the Centers for Medicare & Medicaid Services (CMS) “immediately” refocused its inspections on infection control, with a directive to that effect issued March 4, 2020.

But according to Steed, part of the problem that COVID-19 posed in terms of infection control was the historic lack of resources for the position in long-term care. Part of this is financial; during a webinar discussing a report on the outcomes of COVID-19 in nursing homes, DeWitt noted that he could not find an infection control nurse willing to work for a $70,000 salary.

Part of it too is the variations in the needs of SNFs, at least according to a proposed rule from CMS in 2019 that seemed geared toward accommodating this reality — and that has generated harsh retrospective criticism in the wake of COVID-19.

“We propose to remove the requirement that the infection preventionist (IP) work at the facility ‘part-time’ or have frequent contact with the infection prevention and control program (IPCP) staff at the facility,” the proposed rule from *July of 2019 indicates. “We will instead require that the facility must ensure that the IP has sufficient time at the facility to meet the objectives of its IPCP.”

But given the demands of the role itself, sufficient time is still a significant amount of time. In a very small hospital facility, it’s possible an IP could be part-time, Steed noted.

And while there are many small nursing homes, the fact that long-term care facilities serve as people’s homes is a complicating factor for any IP role in that setting, she added.

According to Steed, the duties of an IP include identifying facility-associated infections, through such means as:

  • Conducting surveillance, wherein all residents are monitored for any infections they develop.
  • From that surveillance, identifying opportunities for infection control measures and implementing those measures, such as monitoring vaccine rates for illnesses like the seasonal flu — or COVID-19.
  • Establishing infection prevention standards

In a place people consider home, such as a nursing home — where some residents may have dementia or challenges remembering to do things like keep a mask on or stay at a distance from others — the infection preventionist would have to establish standards of movement and taking those resident limitations around protocols into account, Steed said.

That’s part of the reason APIC is trying to boost its membership from long-term care facilities. In a recent survey, 8% selected long-term care as their primary practice setting, out of 1,166 responses to that question, and 12% selected it as their secondary practice setting, out of 1,047 responses, according to a spokesperson for the association. Respondents could only choose one setting for their primary one, but could choose multiple settings for their secondary practice.

APIC is also working on putting together “an in-depth analysis” of the needs of long-term care, Steed said, through a contract with a consultant to conduct a practice analysis for documenting the knowledge, skills, and abilities for IP practice in that setting. The goal is to better meet the educational needs of IPs in that setting.

“In acute care, the patients come in to receive care to make them better, and then they go home,” she explained. “The long-term care facility is a place where people live. They’re there because they need help with their activities of daily living … They have rights as it being a place for where they reside and live that have to be taken into consideration.”

*This article originally misstated the month of the proposed rule; it was July of 2019, not November of 2019. SNN regrets the error.