We’ve seen the trends: The elderly population in the U.S. is rapidly increasing, and people over age 65 will make up 20 percent of the U.S. population by 2030.4 As this population ages, the demand for elderly care is growing as healthcare shifts from acute care hospitals to post-acute settings. And most Americans over age 65 are expected to need long-term care facilities and services at some point in their lives.

With the rise of the long-term care population comes an increasing need to prevent infections in long-term care facilities (LTCFs), which have historically been plagued with high rates of healthcare-associated infections (HAIs).

Studies show that HAI rates among elderly residents ranged from 1.8–15.5 infections per 1,000 days in LTCFs vs. 0.95–13 infections per 1,000 days reported in an acute care setting.10, 12 Additionally, the Centers for Disease Control and Prevention (CDC) reports that approximately 388,000 people die each year in LTCFs as a result of these infections.5

Two Key Drivers of Infection Rates in Long-Term Care

There are two main drivers of the infection rates in LTCFs:

  1. Aging populations are more at risk for infection. This is due to a variety of factors including the general frailty of advancing age, the complexity of having multiple chronic conditions, prolonged stays in healthcare settings and overexposure to antibiotics.1 This overexposure to antibiotics places them at risk for antibiotic-resistant bacteria and infections, as well as Clostridiodes difficile (C. diff) gastroenteritis.2
  2. Infection control and prevention programs in LTCFs are typically not as robust as acute care programs. Unfortunately, LTFCs experience a general lack of resources versus acute care, including inadequate funding, challenges hiring and retaining skilled staff and a lack of infection control research in these settings. These limited resources directly impact the ability to develop and maintain quality infection control programs LTCFs.11

According to studies, thousands of outbreaks including influenza, norovirus, and C. diff gastroenteritis occur every year in LTCFs.12 These infections can cause significant pain and discomfort for residents, as well as adverse outcomes, including death. And the really sad part? Most of these infections are preventable.

New Regulations to Incentivize LTCFs

The government is stepping in with new regulations to incentivize LTCFs to put more robust infection prevention and control programs in place.

Triggered by the Affordable Care Act (ACA) and the IMPACT Act of 2014, the Centers for Medicare and Medicaid (CMS) has revised its requirements for LTCFs to receive funding. While some of the requirements are not new, they are now a must do rather than a should do. These new, must-do requirements are:

  1. The facility must designate one or more individuals as infection preventionists (IPs) responsible for the infection prevention and control program (IPCP). IPs must meet three requirements.
    1. They must have primary professional training in nursing, medical technology, microbiology, epidemiology or a related field.
    2. They must be qualified by education, training, experience or certification.
    3. IPs must have sufficient time at the facility to meet the objectives set forth in the facility’s IPCP.
  2. The facility must have a system in place for prevention; identification; recording; reporting; investigation and control of communicable diseases; healthcare-acquired infections and foodborne infections. Further, accepted national standards should be used.
  3. IPs must establish ongoing surveillance systems to collect, analyze, interpret and share infection data for the purpose of reducing morbidity and mortality and to improve health.3
  4. An antimicrobial stewardship program (ASP) must be established that includes antibiotic use protocols and a system for monitoring antibiotic use.2, 7 
  5. There must be a forum for oversight since we should never collect data for the sake of collecting data. This is where the quarterly Quality Assurance and Performance Improvement (QAPI) committee comes into play. 
  6. There must be sanitary management of linens including handling, storing, processing and transport. 
  7. The facility must conduct an annual review of its IPCP and update it as national standards and guidelines change.
  8. The facility must implement process surveillance, which is essentially the routine monitoring of compliance with various infection control practices. Examples include monitoring of hand hygiene, isolation practices, use of personal protective equipment (PPE), injection safety, point-of-care testing, linen management and cleaning and disinfection products and practices. 

Data should be collected and reported along with the HAI rates in the QAPI meeting. Action taken in response to the data needs to be documented. Such action might include staff education or evaluation of new products. Remember: “Not documented = not done.”

The new regulations require that the facility has written standards, policies and procedures that are based on recognized evidence-based guidelines.

These include, but are not limited to:

  1. Hand hygiene including the need for the facility to have readily accessible sinks and alcohol-based hand rubs in appropriate areas including resident care areas and food and medication preparation areas. 
  2. Standard and transmission-based isolation precautions, including how and when to use them.
  3. Resident room assignments including infection status and likelihood of transmission. For a resident with a communicable disease, isolation practices must be the least restrictive possible given the circumstances.

    There must be a communication process for the interfacility transfer of residents who are infected or colonized residents with communicable diseases or other epidemiologically important organisms. LTFCs can simply use the CDC’s interfacility infection control transfer form.
  4. Personal protective equipment (PPE) including selection, donning and doffing.
  5. Cleaning and disinfection of environmental surfaces and shared resident care equipment to provide a clean and sanitary environment to reduce the risk of pathogen transmission.
  6. Staff education and competency assessment to ensure compliance with infection control practice.
  7. Infection control education for residents and family members, including hand hygiene and cough etiquette.

On November 28, 2019, LTCFs participating in Medicare must be in full compliance with these new rules.

Surveyors will be looking for compliance with these new regulations during facility site visits. LTCFs that are not in compliance with CMS regulations can be denied payment and may even be terminated from participation in Medicare and/or Medicaid.6 With more than half of its funding coming from CMS, LTCFs cannot afford to be noncompliant with the new regulations9 and must enact change immediately.

All these new requirements can be overwhelming, so check back next week for my top tips to build a compliant infection prevention and control plan for long-term care facilities.

Click here to read part 2 of our series on long-term infection control.


1. Agency for Healthcare Research & Quality. (2018). Long-Term Care and Patient Safety. Retrieved from www.ahrq.gov.
2. Association for Professionals in Infection Control & Epidemiology. (2017). Significant Gaps in Infection Prevention Impact Long-term Care Residents. Retrieved from www.apic.org.
3. Centers for Disease Control and Prevention. (2001). Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50:1-35.
4. Centers for Disease Control & Prevention. (2013). The State of Aging and Health in America 2013. Retrieved from www.cdc.gov.
5. Centers for Disease Control & Prevention. (2017). Nursing Homes and Assisted Living (Long-term Care Facilities [LTCFs]). Retrieved from www.cdc.gov.
6. Centers for Medicare & Medicaid Services. (2016). Nursing Home Enforcement. Retrieved from www.cms.gov.
7. Centers for Medicare & Medicaid Services. (2017). State Operations Manual: Appendix PP – Guidance to Surveyors for Long-Term Care Facilities. Retrieved from www.cms.gov.
8. Health & Human Services Administration on Aging. (2017). Long-Term Care: The Basics. Retrieved from www.longtermcare.gov.
9. Health Care Association of Michigan. (n.d.). How Nursing Facilities are Funded. Retrieved from www.hcam.org.
10. Klevens, R., Edwards, J., Richards, C., Horan, T., Gaynes, R., Pollock, D., and Cardo, D. (2007). Estimating Health-Care Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Rep, 122(2): 160-166.
11. National Care Planning Council. (2017). About Nursing Homes. Retrieved from https://www.longtermcarelink.net/eldercare/nursing_home.htm
12. Smith, P., Bennett, G., Bradley, S., Drinka, P., Lautenbach, E., Marx, J., Stevenson, K. (2008). SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility. Infect Control Hosp Epidemiol, 29(9): 785-814.