Infection Control in Home Health and Hospice: What 484.70 and 418.60 Expect in the Bag and in the Chart

A surveyor rides along on a wound care visit. The nurse washes her hands, then sets the supply bag on the patient's couch, reuses the same blood pressure cuff she used at the last house without wiping it, and leaves the soiled dressing in a bag next to the clean supplies on the way out. The policy binder at the office is excellent. The citation is written from what happened on the couch.

Infection control in home health and hospice is judged in the home first and in the chart second. This guide sets out what the two conditions of participation require, how surveyors are told to check them, a field practice standard built from CMS's own guidance, and the surveillance and education records that turn good habits into a documented program.

The Rules: Shorter Than You Think

The home health rule, 42 CFR 484.70, has three standards. The agency must maintain and document an infection control program aimed at preventing and controlling infections and communicable diseases, and:

• Prevention: follow accepted standards of practice, including standard precautions.
• Control: run a coordinated, agency-wide program for surveillance, identification, prevention, control and investigation of infectious and communicable diseases, as an integral part of QAPI, including a method for identifying problems and a plan for actions expected to improve outcomes.
• Education: provide infection control education to staff, patients and caregivers.

The hospice rule, 42 CFR 418.60, mirrors it, with two differences worth noticing. The program must protect patients, families, visitors and hospice personnel. And education must reach employees, contracted providers, patients, family members and other caregivers. In hospice, the aide from a contracted agency and the daughter giving morphine at 3am are both inside the education requirement.

Personal care agencies are not under either condition of participation. Their infection control duties come from state licensing rules, which vary, so check your state's home care licensure chapter before assuming the federal text applies.

How Surveyors Check Infection Control in Home Health

The interpretive guidelines in State Operations Manual Appendix B, for home health agencies, explain why the home is harder: care is delivered outside a structured facility, sterile supplies are transported by staff and may need to be stored in the home, and patients may lack basic hygiene necessities. The survey procedures tell surveyors to focus on observing infection control practices during home visits and to compare what they see with the agency's policies. The guidelines also warn that deficiencies at the standard level can add up to a condition-level citation.

Three tags carry the requirements: G682 for prevention, G684 for control and G686 for education. For G682, the guidance says an agency should identify the source of the standards it chose and be able to explain why. CDC, the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America are named as examples. Your policy should say which standards you follow, by name and version.

Hospice surveys run on Appendix M, where tags L577 to L582 cover 418.60. The hospice guidance adds that the program must identify risks in all settings where patients reside, and lists protocols a program may include for infusion therapy, urinary tract care, respiratory tract care, wound care and multi-drug resistant organisms. It also says a deficiency cited against an accepted standard of practice must come with a copy of that standard.

The Bag and the Visit: A Field Standard

Appendix B organizes prevention around six core practices drawn from CDC's Core Infection Prevention and Control Practices, which CDC says apply in all settings where healthcare is delivered, including homes. Turned into a visit routine:

1. 1.Hand hygiene at the right moments. Before and after patient contact, before an aseptic task such as wound care or preparing an injection, after contact with blood, body fluids or contaminated surfaces, after touching the patient's surroundings, when moving from a contaminated to a clean body site, and after removing gloves or other PPE. The guidance says alcohol-based products are preferred when hands are not visibly soiled, and the agency must supply what staff need.
2. 2.A clean surface before anything comes out of the bag. The guidance suggests cleaning and disinfecting, or placing a clean barrier on, the surface where clean equipment goes or where injectable medications are prepared. The couch in the opening example fails this step.
3. 3.Injection and medication safety. Aseptic technique, no reuse of needles, lancets or syringes, single-dose vials whenever possible and never shared between patients, a new needle and syringe for every entry into a container, insulin pens dedicated to one patient even if the needle is changed, and sharps disposal under state and local rules.
4. 4.PPE chosen by the task. Gloves, gowns and face protection selected by the expected exposure, not worn by habit or skipped for speed.
5. 5.Minimized exposures. Attention to respiratory infection spread and to transporting specimens and medical waste, including sharps.
6. 6.Equipment between homes. Reusable items such as glucose meters, blood pressure cuffs and oximeter probes must be reprocessed before use on another patient and when soiled, following manufacturer instructions. Staff must keep clean and soiled equipment separate in the home and in the car.

A simple bag rule makes items 2 and 6 automatic: the bag never touches the floor or upholstered furniture, clean items go back into the bag only after hand hygiene, and anything used or soiled leaves the home in a separate container. Agencies set their own bag procedure; write yours down and teach it with a return demonstration.

Surveillance: The Part Most Agencies Under-Document

G684 is where well-run agencies lose points, because good field practice without data is not a program. Appendix B says the agency chooses its own method for identifying infections and gives examples: clinical record review, staff reporting, laboratory results, analysis of practitioner and emergency room visits for symptoms of infection, and root cause review of staff and patient technique. It also suggests, without requiring it, a way to receive CDC Health Alert Network or local public health alerts.

A workable monthly surveillance routine:

1. 1.Collect. New infections among active patients by type (urinary tract, wound, respiratory, line-related), from visit notes, hospitalizations and lab results.
2. 2.Calculate a rate. Infections per 1,000 patient days, by type. With illustrative numbers: 6 new wound infections across 3,000 patient days in a month is 2.0 per 1,000.
3. 3.Look for a cause. For each cluster, review technique: dressing changes, catheter care, caregiver self-care.
4. 4.Act and record. A policy change, retraining, or a patient education change, with an owner and a date.
5. 5.Report to QAPI. Both rules make the program part of QAPI. The minutes should show the data, the action and whether it worked.

Track staff illness alongside patient infections. The Appendix M guidance gives that as an example practice for hospices, and it connects directly to your work restriction policy. The flu season staffing guide covers return-to-work criteria, and the TB testing guide covers baseline screening and exposure follow-up, so this program does not need to repeat either.

Education That Satisfies Both Rules

The Appendix B guidance for G686 says the regulation does not specify the form or content of education, then lists what staff education should include: equipment use, transport, storage and cleaning by manufacturer instructions; job-specific training for every task; competency processes; current written policies; training before staff perform duties, with periodic refreshers; extra training after lapses or when new equipment or threats appear; and education at orientation, annually and as needed. For patients and caregivers, education should match the plan of care and be reinforced, for example on cleaning a glucose meter or a reusable catheter.

Build a matrix with four rows: employees, contracted staff (hospice), patients, and family caregivers. For each, record what is taught, when, by whom, and how competence is shown. A signed sheet proves attendance. A return demonstration, observed and documented, proves competence.

A Pre-Survey Self-Check

1. 1.Does the policy name its standards of practice and their versions?
2. 2.Has a supervisor observed every clinician's bag technique and hand hygiene in a home this year, with a written record?
3. 3.Is reusable equipment cleaning documented, and does it follow the manufacturer's instructions?
4. 4.Are surveillance data, analysis and actions in the QAPI minutes for each of the last three months?
5. 5.Does every patient record show infection control teaching tied to the plan of care?
6. 6.For hospices, do contracted staff and family caregivers appear in the education records?

Where Systems Help

The two weak points are observation records and surveillance data, because both live on paper in most agencies. Nuraflow is being designed so that care delivery puts precautions and plan-derived tasks in front of staff at the visit, and onboarding, orientation and training records orientation, competencies and course completion in the employee file.

This article is general information, not clinical advice. Have your director of nursing or infection preventionist review your program against the current regulations, the State Operations Manual and your state's licensing rules.