N.Y. Public Health Law Section 2803-AA*2
Nursing home infection control competency audit

1.

The commissioner shall establish in the department a program for audits of nursing homes to measure specific core competencies relating to infection control of each nursing home. The audits shall commence on December 1, 2022, and shall be conducted annually thereafter.

2.

(a) The audit shall utilize a checklist that is consistent with focused infection control survey standards issued by the federal centers for Medicare and Medicaid services to evaluate infection control competency of each nursing home.

(b)

A nursing home must meet all metrics on the checklist developed pursuant to paragraph (a) of this subdivision to be scored as in compliance with infection control.

(c)

If a nursing home fails to meet all metrics on the checklist developed pursuant to paragraph (a) of this subdivision, the department shall conduct another infection control audit within ninety days of the initial determination. The department shall continue to conduct such ninety day audits until the nursing home is scored as in compliance with infection control competency. The department may also pursue administrative penalties, including but not limited to citation for violation of infection control standards and imposing civil monetary penalties pursuant to § 12 (Violations of health laws or regulations)section twelve of this chapter.

3.

An audit of core competencies shall include, but not be limited to, the following, and shall be consistent with focused infection control survey standards issued by the federal centers for Medicare and Medicaid services:

(a)

Infection control.

(i)

The nursing home shall assign an infection lead staff person to implement infection control based on federal and state public health advisories, guidelines and rules.

(ii)

The nursing home shall have a written infection control program which includes, but is not limited to: (A) A plan to investigate, control and take action to prevent infections in the nursing home; (B) Procedures for isolation and universal precautions for residents suspected or confirmed to have a contagious or infectious disease; and (C) A record of incidences and corrective actions related to infections at the nursing home.

(iii)

During an officially declared national emergency, or state or municipal emergency declared pursuant to article two-B of the executive law, related to a contagious or infectious disease outbreak, the nursing home shall have screening requirements for every individual entering the facility, including staff, for symptoms associated with the infectious disease outbreak.

(iv)

The nursing home shall have a staffing and cohorting plan to limit transmission, which is based on national (for example, centers of disease control and centers for Medicare and Medicaid services), state or local public health authority recommendations. Such staffing and cohorting plan may include, but not be limited to: (A) Having dedicated, consistent staffing teams who directly interact with residents that are confirmed or suspected to be infected with a contagious or infectious disease; (B) Limiting clinical and other staff who have direct resident contact to specific areas of the facility and not rotating staff between various areas of the facility during the period they are working each day during periods of recognized outbreaks; and (C) Having a dedicated space in the facility for cohorting and managing care for residents with an infectious disease, such as COVID-19.

(v)

The nursing home shall ensure ongoing access to the necessary supplies for hand hygiene for staff and residents, hospital disinfectants or alternatives to allow for necessary and appropriate cleaning and disinfecting of surfaces and shared resident care equipment.

(vi)

The nursing home shall train staff and establish protocols for selecting, donning and doffing appropriate personal protective equipment and demonstrate competency during resident care. The nursing home must keep a record of staff training in proper storage, use, reuse, and disposal of personal protective equipment.

(vii)

The nursing home must designate a staff member or members who is responsible for ensuring the proper use of personal protective equipment by all staff.

(b)

The nursing home shall demonstrate that there has been advanced planning, in alignment with the facility’s emergency preparedness plans and pandemic emergency plan, for contingent staffing needs in the case of staff quarantines that shall have an employee responsible for conducting a daily assessment of staffing status and needs during an outbreak of infectious or contagious diseases, and institute a sick-leave policy that does not punish staff with disciplinary action if they are absent from work because they are exhibiting symptoms, or test positive, for an infectious disease. Such policies shall offer the maximum amount of flexibility to staff and be consistent with state guidance.

(c)

The nursing home shall have a written plan for daily communications with staff, residents, and the residents’ families regarding the status of infections at the nursing home. Such plan shall be consistent with the requirements set forth in paragraph (a) of subdivision twelve of § 2803 (Commissioner and council)section twenty-eight hundred three of this article. The nursing home must designate one or more staff members who are responsible for these communications with staff, residents and residents’ families. * NB There are 2 § 2803-aa’s

Source: Section 2803-AA*2 — Nursing home infection control competency audit, https://www.­nysenate.­gov/legislation/laws/PBH/2803-AA*2 (updated Apr. 1, 2022; accessed Apr. 27, 2024).

2800
Declaration of policy and statement of purpose 2801
Definitions 2801‑A
Establishment or incorporation of hospitals 2801‑B
Improper practices in hospital staff appointments and extension of professional privileges prohibited 2801‑C
Injunctions 2801‑D
Private actions by patients of residential health care facilities 2801‑E
Voluntary residential health care facility rightsizing demonstration program 2801‑F
Residential health care facility quality incentive payment program 2801‑G
Community forum on hospital closure 2801‑H
Personal caregiving and compassionate caregiving visitors to nursing home residents during declared local or state health emergencies 2802
Approval of construction 2802‑A
Transitional care unit demonstration program 2802‑B
Health equity impact assessments 2803
Commissioner and council 2803‑A
Authority to contract 2803‑AA
Sickle cell disease information distribution 2803‑AA*2
Nursing home infection control competency audit 2803‑B
Uniform reports and accounting systems for hospital costs 2803‑C
Rights of patients in certain medical facilities 2803‑C‑1
Rights of patients in certain medical facilities 2803‑C‑2
Lesbian, gay, bisexual and transgender, and people living with HIV long-term care facility residents’ bill of rights 2803‑D
Reporting abuses of persons receiving care or services in residential health care facilities 2803‑E
Residential health care facilities 2803‑E*2
Reporting incidents of possible professional misconduct 2803‑F
Respite projects 2803‑G
Board of visitors in county owned residential health care facility 2803‑H
Health related facility 2803‑I
General hospital inpatient discharge review program 2803‑J
Information for maternity patients 2803‑J*2
Nursing home nurse aide registry 2803‑K
In-patient nasogastric feeding procedures 2803‑L
Community service plans 2803‑M
Discharge of hospital patients to adult homes 2803‑N
Hospital care for maternity patients 2803‑O
Hospital care for mastectomy, lumpectomy, and lymph node dissection patients 2803‑O‑1
Required protocols for fetal demise 2803‑P
Disclosure of information concerning family violence 2803‑Q
Family councils in residential health care facilities 2803‑R
Dissemination of information about the abandoned infant protection act 2803‑S
Access to product recall information 2803‑T
Preadmission information 2803‑U
Hospital substance use disorder policies and procedures 2803‑V
Lymphedema information distribution 2803‑V*2
Standing orders for newborn care in a hospital 2803‑W
Independent quality monitors for residential health care facilities 2803‑W*2
Disclosure of information concerning pregnancy complications 2803‑X
Requirements related to nursing homes and related assets and operations 2803‑Y
Provision of residency agreement 2803‑Z
Transfer, discharge and voluntary discharge requirements for residential health care facilities 2803‑Z*2
Antimicrobial resistance prevention and education 2804
Units for hospital and health-related affairs 2804‑A
State task force on clinical practice guidelines and medical technology assessment 2805
Approval of hospitals 2805‑A
Disclosure of financial transactions 2805‑B
Admission of patients and emergency treatment of nonadmitted patients 2805‑C
Every private proprietary nursing home having a capacity of eighty patients or more may have a licensed medical doctor in attendance, upo... 2805‑D
Limitation of medical, dental or podiatric malpractice action based on lack of informed consent 2805‑E
Reports of residential health care facilities 2805‑F
Money deposited or advanced for admittance to nursing homes 2805‑G
Maintenance of records 2805‑H
Immunizations 2805‑I
Treatment of sexual offense victims and maintenance of evidence in a sexual offense 2805‑J
Medical, dental and podiatric malpractice prevention program 2805‑K
Investigations prior to granting or renewing privileges 2805‑L
Adverse event reporting 2805‑M
Confidentiality 2805‑N
Child abuse prevention 2805‑O
Identification of veterans and their spouses by nursing homes, residential health care facilities, and adult care facilities 2805‑P
Emergency treatment of rape survivors 2805‑Q
Hospital visitation by domestic partner 2805‑R
Patients unable to verbally communicate 2805‑S
Circulating nurse required 2805‑T
Clinical staffing committees and disclosure of nursing quality indicators 2805‑U
Credentialing and privileging of health care practitioners providing telemedicine services 2805‑V
Observation services 2805‑W
Patient notice of observation services 2805‑X
Hospital-home care-physician collaboration program 2805‑Y
Identification and assessment of human trafficking victims 2805‑Z
Hospital domestic violence policies and procedures 2806
Hospital operating certificates 2806‑A
Temporary operator 2806‑B
Residential health care facilities 2807
Hospital reimbursement provisions 2807‑A
General hospital nineteen hundred eighty-six and nineteen hundred eighty-seven inpatient rates and charges 2807‑AA
Nurse loan repayment program 2807‑B
Outstanding payments and reports due under subdivision eighteen of section twenty-eight hundred seven-c, sections twenty-eight hundred se... 2807‑C
General hospital inpatient reimbursement for annual rate periods beginning on or after January first, nineteen hundred eighty-eight 2807‑D
Hospital assessments 2807‑D‑1
Hospital quality contributions 2807‑DD
Temporary nursing home stability contributions 2807‑E
Uniform bills 2807‑F
Health maintenance organization payment factor 2807‑I
Service and quality improvement grants 2807‑J
Patient services payments 2807‑K
General hospital indigent care pool 2807‑L
Health care initiatives pool distributions 2807‑M
Distribution of the professional education pools 2807‑N
Palliative care education and training 2807‑O
Early intervention services pool 2807‑P
Comprehensive diagnostic and treatment centers indigent care program 2807‑R
Funding for expansion of cancer services 2807‑S
Professional education pool funding 2807‑T
Assessments on covered lives 2807‑U
Transfers for tax credits 2807‑V
Tobacco control and insurance initiatives pool distributions 2807‑W
High need indigent care adjustment pool 2807‑X
Grants for long term care demonstration projects 2807‑Y
Pool administration 2807‑Z
Review of eligible federally qualified health center capital projects 2808
Residential health care facilities 2808‑A
Liability of certain persons 2808‑B
Certification of financial statements and financial information 2808‑C
Reimbursement of general hospital inpatient services 2808‑D
Nursing home quality improvement demonstration program 2808‑E
Residential health care for children with medical fragility in transition to young adults and young adults with medical fragility demonst... 2808‑E*2
Nursing home ratings 2809
Residential health care facilities 2810
Residential health care facilities 2811
Discounts and splitting fees with medical referral services 2812
Construction 2813
Separability 2814
Health networks, global budgeting, and health care demonstrations 2815
Health facility restructuring program 2815‑A
Community health care revolving capital fund 2816
Statewide planning and research cooperative system 2816‑A
Cardiac services information 2817
Community health centers capital program 2818
Health care efficiency and affordability law of New Yorkers (HEAL NY) capital grant program 2819
Hospital acquired infection reporting 2820
Home based primary care for the elderly demonstration project 2821
State electronic health records (EHR) loan program 2822
Residential care off-site facility demonstration project 2823
Supportive housing development program 2824
Central service technicians 2824*2
Surgical technology and surgical technologists 2825
Capital restructuring financing program 2825‑A
Health care facility transformation program: Kings county project 2825‑B
Oneida county health care facility transformation program: Oneida county project 2825‑C
Essential health care provider support program 2825‑D
Health care facility transformation program: statewide 2825‑E
Health care facility transformation program: statewide II 2825‑F
Health care facility transformation program: statewide III 2825‑G
Health care facility transformation program: statewide IV 2825‑H
Health care facility transformation program: statewide V 2826
Temporary adjustment to reimbursement rates 2827
Plant-based food options 2828
Residential health care facilities 2828*2
Essential support persons allowed for individuals with disabilities during a state of emergency 2829
Nursing homes 2830
Surgical smoke evacuation 2830*2
Regulation of the billing of facility fees
Green check means up to date. Up to date

Accessed:
Apr. 27, 2024

Last modified:
Apr. 1, 2022

§ 2803-AA*2’s source at nysenate​.gov

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