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Solutions: A Blog for Health Care Professionals

May 1, 2012

Marci Pederson, RN, BSN, Nurse Educator/Consultant, Avera Education & Staffing Solutions

F441—Facility Establishes Infection Control Program

South Dakota long-term care facilities had 66 deficiencies cited for F441 in 2011. It ranked number one in the top twenty deficiencies for long-term care facilities in South Dakota.


Regulation F441 states:

483.65 Infection Control

The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

483.65(a) Infection Control Program

The facility must establish an infection control program under which it ---

1. Investigates, controls, and prevents infections in the facility;

2. Decides what procedures, such as isolation should be applied to an individual resident; and

3. Maintains a record of incidents and corrective actions related to infections.

483.65(b) Preventing Spread of Infection

1. When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate resident.

2. The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.

3. The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

483.65(c) Linens

Personnel must handle, store, process and transport linens so as to prevent the spread of infection.


There has been a significant increase in the number of deficiencies written for F441 in the past three years: 2009 – 18 deficiencies; 2010 – 49 deficiencies; and 2011 – 66 deficiencies. When I inquired about what aspect of infection control is most cited, the answer was hand washing. On   9-30-09 a new Guidance to Surveyors for F441 was implemented which provided long-term care facilities and surveyors excellent information on infection control. Facilities utilizing this information to set up or revise their infection control programs should find the Guidance to Surveyors a helpful guide in the process. The new Guidance to Surveyors provides surveyors with guidance to more fully investigate facilities' compliance with the Infection Control regulation. Why an increase in deficiencies? There could be a variety of answers. Surveyors may be more consistent in how they investigate the facilities' compliance with this regulation, but the facilities could also be more consistent in the implementation of their Infection Control Programs. I am going to list the areas in need of improvement based on what I observe:

When providing direct care, staff must remove their gloves, do hand hygiene and re-glove when they go from a dirty task to a clean task. This occurs most frequently after peri-care is provided to residents during toileting or changing incontinent briefs.When distributing fresh water, staff must do hand hygiene in between distributing fresh water to roommates. Cross-contamination has been observed during this process. I have seen consistent hand hygiene in between rooms, but not between staff contact with roommates.During mealtimes, direct care staff assisting residents must do hand hygiene after they have touched eating utensils one resident has touched and before touching eating utensils another resident will touch.When distributing personal laundry or any clean laundry, there should be a dust protector in place on the clean laundry during the process.

When staff does not follow standards of practice pertaining to hand washing and infection control, they are breaking the law and putting themselves and their residents in danger. This sounds harsh, but it is true. Some of us may even be in denial about this. To improve, facilities need to be pro-active in their Process Surveillance, a required part of an Infection Control Program. A system of monitoring for proper hand hygiene and use and disposal of gloves is a must.  A reward system can be helpful to reinforce excellent hand hygiene.

The Influenza season is late this year, and we are seeing an increase now in the numbers of cases.  Being vaccinated for influenza is not effective by itself unless we all are conscientious about our hand hygiene.

If your facility would like to improve regulatory compliance and quality of care pertaining to infection control, contact us at (605) 668-8475 for solutions.  We have a very helpful two-part Infection Control webinar available which focuses on the F441 Infection Control Guidance to Surveyors.

Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.