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 Jul. 6, 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‑FF
New York managed care organization provider tax
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
2825‑I
Healthcare safety net transformation program
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

Accessed:
Jul. 6, 2024

Last modified:
Apr. 1, 2022

§ 2803-AA*2’s source at nysenate​.gov

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