Infection Control Policies and Procedures Manual

Operating Procedures Medical Services
Tri-County Behavioral Healthcare Infection Control Program Manual
INFECTION CONTROL POLICIES AND PROCEDURES MANUAL

TABLE OF CONTENTS
1 PURPOSE.......................................................................................................................................... 3
2 SCOPE .............................................................................................................................................. 3
3 EMPLOYEE TRAINING........................................................................................................................ 3
4 AVAILABILITY AND DISTRIBUTION OF INFECTION CONTROL POLICIES AND PROCEDURES .................... 3
5 DESIGNATION OF RESPONSIBILITIES .................................................................................................. 3
5.1 All Employees ................................................................................................................................... 3
5.2 Infection Control Committee ........................................................................................................... 3
5.3 Infection Control Committee Chair/Center-wide Infection Control Officer .................................... 4
5.4 Facility Infection Control Officer ...................................................................................................... 4
6 EMPLOYEE HEALTH SCREENING AND PREVENTION ACTIVITIES ........................................................... 5
6.1 Tuberculosis (TB) Screening ............................................................................................................. 5
6.2 Hepatitis B Vaccine .......................................................................................................................... 5
6.3 Influenza Vaccine ............................................................................................................................. 6
7 SIGNIFICANT INFECTIONS.................................................................................................................. 6
7.1 Definition of Significant Infections ................................................................................................... 6
7.2 Examples of Significant Communicable Diseases and Infections: ................................................... 7
7.3 Reportable Infections and Communicable Diseases ........................................................................ 7
7.4 Local Health Department Contact Information ............................................................................... 8
Montgomery County Public Health Department ....................................................................... 8
Liberty County Public Health Department ................................................................................. 8
Walker County Hospital District................................................................................................. 8
8 NOSOCOMIAL AND COMMUNITY-ACQUIRED INFECTIONS.................................................................. 8
8.1 Nosocomial Infections...................................................................................................................... 8
8.2 Community-Acquired Infections ...................................................................................................... 8
9 GENERAL METHODS OF PREVENTION AND CONTROL ......................................................................... 9
9.1 Interventions/Methods to Reduce the Risk of Infection Transmission ........................................... 9
Standard Blood and Bodily Fluid Precautions ............................................................................ 9
Personal Protective Equipment.................................................................................................. 9
Diseases Transmitted Through Air-Borne Contamination ....................................................... 10
Handwashing Techniques ........................................................................................................ 10
Staph Infection/MRSA ............................................................................................................. 11
10 DIRECTIVES AND GUIDELINES TO PREVENT AND CONTROL THE TRANSMISSION OF INFECTION...... 11
10.1 Assault ............................................................................................................................................ 11
10.2 Management of Human Bites ........................................................................................................ 11
10.3 Needles and Syringes and Incidents of Needle-Stick ..................................................................... 12
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10.4 Thermometer Care......................................................................................................................... 14

10.5 Decontaminating Mannequins Used in CPR Training .................................................................... 14
10.6 Pet Vaccinations ............................................................................................................................. 14
10.7 Re-use of Disposable Items ............................................................................................................ 15
10.8 The Storage and Quality Control of Sterile Equipment and Medical Supplies .............................. 15
10.9 Toys - Procedures for Cleaning and Disinfecting Environmental Surfaces .................................... 15
10.10 Disposal of Infectious Waste .......................................................................................................... 15
10.11 Cleaning and Decontaminating After Blood Spills ......................................................................... 16
10.12 Lab Specimen and Storage ............................................................................................................. 16
10.13 Care of Individual's Personal Needs and Items .............................................................................. 17
10.14 Precautionary Measures and Monitoring for Possible Outbreak of Bedbugs ............................... 17
10.15 Management of Suspected Bedbugs in PETC and IDD Residential Programs................................ 17
11 SURVEILLANCE OF INFECTIONS .................................................................................................... 19
11.1 Reporting and Documenting Employee Illnesses........................................................................... 19
11.2 Reporting and Documenting Patient Illness .................................................................................. 19
11.3 Identification of Illnesses which may Allow Continuation or Exclusions from TCBHC Programs .. 19
11.4 Documenting Potential Infection Control Issues ........................................................................... 21
11.5 Reviewing Infection Control Data .................................................................................................. 21
12 POST-EXPOSURE MANAGEMENT OF CHRONIC STATE INFECTIONS (HIV, HBV, AND TB) .................. 22
12.1 Post Exposure Management for TB ............................................................................................... 22
12.2 Post Exposure Management for HepB ........................................................................................... 22
12.3 Post Exposure Management for HIV .............................................................................................. 23
13 MANAGEMENT OF EMPLOYEES OR INDIVIDUALS WITH HIV AND HBV .......................................... 23
13.1 Limitation of Activities for Patients................................................................................................ 23
13.2 Employees with HIV or AIDS .......................................................................................................... 24
14 DIETARY ..................................................................................................................................... 24
14.1 Personnel Handling Food for Individuals ....................................................................................... 24
14.2 Food Preparation ........................................................................................................................... 24
15 GENERAL HOUSEKEEPING ........................................................................................................... 26
16 PEST CONTROL ........................................................................................................................... 27
16.1 Insects ............................................................................................................................................ 27
16.2 Rodents .......................................................................................................................................... 28
17 EDUCATION ................................................................................................................................ 28
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INFECTION CONTROL POLICIES AND PROCEDURES MANUAL
1. PURPOSE
Tri-County Behavioral Healthcare (Tri-County) has endorsed the development of a comprehensive
Infection Control Program for distribution to, and use by, its employees and contractors. Effective
infection control practices will ensure quality care for the individuals participating in services. The
Infection Control Program Manual provides the basic information needed to promote awareness of
infection surveillance, prevention, and control practices. Each Tri-County unit will endeavor to provide an
environment that will protect all individuals served, employees and visitors from sources and transmission
of infections.
2. SCOPE
The Centers for Disease Control (CDC) suggests that infection control should ideally include surveillance
for both infections and individual care practices, developing infection control policies, and training and
assisting employees with approaches to preventing and controlling infections in individuals receiving
services, as well as in themselves.
3. EMPLOYEE TRAINING
Training for all employees is conducted prior to initial assignment to tasks where occupational exposure
to bloodborne pathogens may occur. All employees also receive annual refresher training that is to be
conducted within one year of the employee’s previous training. Refresher trainings are completed
through Relias Essential Learning. Additional infection control training will be scheduled as needed with
individual employee, when procedures change, or new infection control officers are hired.
4. AVAILABILITY AND DISTRIBUTION OF INFECTION CONTROL POLICIES AND PROCEDURES

The Infection Control Plan shall be included within the Tri-County Behavioral Healthcare Procedures. All
employees shall have access to infection control policies and procedures.
5. DESIGNATION OF RESPONSIBILITIES
5.1 All Employees
Awareness and competency to participate in infection surveillance, prevention, and control
activities shall be required of every employee. All employees are expected to cooperate with their
supervisors in meeting conditions specified by the Infection Control Committee in the event of an
infectious epidemic. Reporting potential infections/diseases/infestations is the responsibility of
all employee. The information will be provided to the Infection Control Committee and the Risk
Manager by completion of an Incident Report.
5.2 Infection Control Committee
The Infection Control Committee at Tri-County has been established and charged with the
responsibility for surveillance, prevention and control of infections. The Committee, with the
approval of the Management Team (MT), has the authority to institute any surveillance,
prevention and control measures when there is an indication that the health of consumers or
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employee is at risk. The Management Team shall recommend committee members and the
members are appointed by the Executive Director.
A. The Infection Control Committee members are recommended for appointment by
Management Team members and appointments are made by the Executive Director.
Permanent members include but are not limited to:
1. Outpatient Director of Nursing – Chair/Center-wide Infection Control Officer
2. Medical Director
3. Administrator of Risk Management
4. PETC Director of Nursing
5. Administrator of Quality Management
B. The Infection Control Committee meets on a quarterly basis. In addition, special meetings
are held when necessary. Meetings are open to committee members only, however, any
other individuals who wish to attend a meeting in reference to any infection
control/safety concern, may do so by contacting the chairperson.
C. The Infection Control Committee will:
1. Review and present new infection control guidelines and revisions to the
Management Team for review and approval.
2. Develop, review, and approve the written Infection Control Program Manual and
submit to Management Team for review and approval annually.
3. Develop, implement, manage, monitor, and evaluate the effectiveness of the
various infection control activities within the Center.
4. Review, analyze and discuss infection control/safety data and concerns.
5. Conduct internal reviews in coordination with the Safety Committee. Prevention,
surveillance and control of infections is the responsibility of the Infection Control
Committee.
5.3 Infection Control Committee Chair/Center-wide Infection Control Officer
The Tri-County Infection Control Officer shall have documented training. For licensed nurses
serving the role of Infection Control Officer, evidence of nursing licensure may fulfill this
requirement. The Infection Control Officer may acquire this knowledge through formal course
work or short courses or seminars in the principles of infection prevention, surveillance, and
control. Responsibilities include:
A. Monitor infection control training for all new employees, and implement or assist with
annual updates and ongoing training on infection control practices;
B. Report infection control issues to Infection Control Committee and Management Team;
C. Coordinate any vaccination or educational programs for prevention of communicable
diseases developed by the center;
D. Conducts all Infection Control meetings and facilitates group processes;
E. Provide consultation to the Infection Control Committee;
F. Review infection/safety related Incident/Injury Reports, and other related infection
reports and make information available as appropriate for review by the Infection Control
Committee while removing any employee identifying information; and
G. Submit infection control reports quarterly to the Management Team as requested.
5.4 Facility Infection Control Officer

The Facility Infection Control Officer is responsible for the following:
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A. Demonstrates knowledge of the definitions of significant infection, nosocomial and

community acquired infections.
B. Demonstrates knowledge of infection prevention and control measures.
C. Communicates infection control issues or needs to the Tri-County Infection Control
Committee Chair/Center-wide Infection Control Officer.
D. Report any hazards, unusual occurrences, or epidemics of infection immediately.
E. Monitors employee infection control practices, including standard precautions and
regular handwashing.
F. Maintain personal protective equipment (PPE) and supplies at the facility at all times.
G. Ensure infectious wastes are properly handled and disposed of.
H. Submits a Quarterly Infection Surveillance Log and Summary to the Infection Control
Committee Chair/Center-wide Infection Control Officer.
6. EMPLOYEE HEALTH SCREENING AND PREVENTION ACTIVITIES

Refer to Standard Precautions (Attachment 1) for the accepted prevention methods recommended by the
Centers for Disease Control and Prevention.
6.1 Tuberculosis (TB) Screening
A. Mycobacterium tuberculosis (TB) is spread by airborne particles, known as droplet nuclei,
which can be generated when persons with pulmonary or laryngeal TB sneeze, cough,
speak, or sing. Infection occurs when a susceptible person inhales droplet nuclei
containing tubercle bacilli.
B. All new employees of Tri-County will receive a baseline Tuberculosis (TB) skin test,
administered by a nurse, during the first week of employment. The TB Skin test is a
subcutaneous injection of purified protein derivative (PPD) of killed tubercle bacilli and is
administered in the inner forearm. The site is examined by a nurse 48 to 72 hours after
injection for indurations (palpable swelling).
1. If the TB skin test is negative, no further action is required.
2. If the TB skin test is positive, the employee will be sent for a chest x-ray at a Tri-
County contracted facility.
3. If employee has history of positive TB skin test or cannot receive TB skin test due
to known allergy, the employee will be sent for chest x-ray.
4. No direct care shall be provided until employee has negative TB skin test or chest
x-ray.
C. All employees will complete an annual TB Screening Questionnaire (Attachment 2). A TB
skin test will be administered for any questionable questionnaire results, or if an
employee displays signs and symptoms of TB (e.g., productive and prolonged cough,
fever, chills, loss of appetite, weight loss, fatigue, or night sweats). Any positive TB skin
test results will follow the above procedure. Annual TB testing is not recommended per
the CDC. Employees who do not obtain a TB skin test or complete a TB Screening
Questionnaire annually will be subject to disciplinary action.
6.2 Hepatitis B Vaccine
A. All employees in Category I (Attachment 3) will be offered the Hepatitis B vaccine at no
cost and will receive the first dose within 10 days of the start of employment. Employee
will complete the Hepatitis B Consent form (Attachment 4).
B. Any employee in Category II (Attachment 3) may receive the vaccine but will be required
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to pay the full cost of the vaccine. Employees, who do not choose to receive or have
received the Hepatitis B vaccine previously, must sign a Hepatitis B Declination
(Attachment 5).
C. Category I employees who previously declined the vaccine may request and obtain the
vaccine at a later date. Employees would notify the Infection Control Committee
Chair/Center-wide Infection Control Officer of this request.
D. The Hepatitis B vaccine provides protection against Hepatitis B, a serious infection that
can result in cirrhosis and cancer of the liver. Hepatitis B is caused by a virus and is spread
through blood and other body fluids. The vaccine provides immunization in about 90%
of recipients. The vaccine is contraindicated in persons who are sensitive to yeast or any
component of the vaccine.
E. Administration is by intramuscular injection in the deltoid muscle (upper arm).
Immunization requires three doses of vaccine according to the following schedule:
1. 1st dose: Initial dose can be given at any time
2. 2nd dose: One month following the initial dose
3. 3rd dose: Six months after the first dose
F. If an employee misses a dose, the employee will be responsible for the cost of completing
the series.
G. Current data from the CDC indicates that vaccine-induced Hepatitis B surface antibody
levels may decline over time; however, immune memory remains intact for at least 30
years among healthy vaccinated individuals following immunization. Persons with
declining antibody levels are still protected against clinical illness and chronic disease.
Booster doses of vaccine are not recommended by the CDC.
6.3 Influenza Vaccine
A. Influenza vaccine is the primary method for preventing influenza and its severe
complications. The vaccine is made from highly purified, egg-grown viruses that have
been made noninfectious (inactivated). Inactivated influenza vaccine contains
noninfectious killed viruses and cannot cause influenza.
B. The vaccine prevents the most current strain of the virus.
C. The most common side effect is soreness at the site of injection.
D. Fever, aches, and tiredness can occur following vaccination.
E. The flu vaccine is offered to all Tri-County employees annually at no cost to the employee.
F. Tri-County Behavioral Healthcare will use CDC information and any other pertinent
educational material obtained though the local Health District, websites, or other
providers to create handouts/posters to educate employees. Handouts and posters will
include information on the vaccine, non-vaccine controls, prevention measures, and the
diagnosis, transmission and impact of influenza. In addition to educational material in the
form of handouts/posters, an email which informs employees that flu vaccines will be
offered, including date, time and locations will be sent out.
G. This program is voluntary.
H. The employee will sign a waiver prior to receiving the vaccination (Attachment 6).
7. SIGNIFICANT INFECTIONS
7.1 Definition of Significant Infections
A. Significant infections are defined for the purpose of educating employees as to what are
reportable conditions. Significant infections include:
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1. Actual infections or conditions for which antibiotics have been prescribed and/or
which have been designated as communicable.
2. Infections considered to be communicable by any route of transmission and/or
to be of enough seriousness to interfere with an individual's participation in daily
activities (i.e., work, school, etc.).
B. Symptoms may signify potential infections (i.e., fever, chills, sore throat, rash, nausea,
vomiting, diarrhea, purulent drainage, persistent cough, runny nose, tissue redness,
swelling, etc.). These symptoms, unless diagnosed by a physician as non-infectious,
should be considered potentially infectious.
7.2 Examples of Significant Communicable Diseases and Infections:
Common Cold Norovirus

Chicken Pox Pertussis (Whooping Cough)
Diphtheria Pink Eye
E. coli Pinworms
Gastroenteritis, Viral Polio
Gonorrhea Ringworm
Head Lice Rubella (German Measles)
Hepatitis, Viral Type A SARS (Severe Acute
Herpes Simplex (cold sores) Respiratory Syndrome)
Impetigo Salmonellosis
Influenza Scabies
Meningitis (viral & bacterial) Shigellosis
MRSA (Methylicillin Resistant Strep Throat
Staphylococcus Aureus) Scarlet Fever
Measles Syphilis
Mumps
7.3 Reportable Infections and Communicable Diseases

A. Reportable infections and communicable diseases as defined by the Texas Department of
State Health Services are listed in Notifiable Conditions (Attachment 7), and footnotes
(Attachment 8).
B. Contact Risk Manager and the Infection Control Committee Chair/Center-wide Infection
Control Office for any reportable diseases. After hours, call 936-537-0218.
C. Common reportable diseases at PETC include:
1. Positive RPR/Syphilis
2. Chlamydia
3. Positive Tuberculosis
D. Procedure:
1. Positive test results are reported to Medical Director.
2. Complete all required forms Initial Provider Infectious Disease Report
(Attachment 17) and/or Confidential Report of Sexually Transmitted Diseases
(STD) (Attachment 18) and fax to Montgomery County Health Department.
3. Include the positive lab results in fax and staple all together.
4. Complete Incident Report (Attachment 13).
5. Call local office to verify receipt.
6. Maintain forms in back of the Infection Control Manual at the nurses’ desk.
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7. Expect follow-up phone contact from their department in days to follow.

E. Reporting infectious disease to public health authorities required by the Texas
Administrative Code Title 25, Part 1, Chapter 97, Subchapter A, Rule 97.2 is the
responsibility of the attending physician, dentist, veterinarian, chiropractor, advanced
practice nurse, or physician assistant.
7.4 Local Health Department Contact Information:
Montgomery County Public Health Department
1300 South Loop 336 West
Conroe, Texas 77301
(936) 523-5020
Liberty County Public Health Department
300 Campbell Street
Cleveland, Texas 77327
(281) 592-6714
Walker County Hospital District
PO Box 1267
Huntsville, Texas 77342
(936) 295-0038
8. NOSOCOMIAL AND COMMUNITY-ACQUIRED INFECTIONS

8.1 Nosocomial Infections
A. Nosocomial infection: An infection that develops during residential placement/treatment
or is contracted from another individual/source within a Tri-County Behavioral Healthcare
facility. In addition, there is no evidence that the infection was present or incubating at
the time of admission. When the incubation period is unknown, an infection is considered
nosocomial if it develops any time after admission. Certain nosocomial infections must be
reported to the local health department.
B. All direct care employees will be trained on the following information regarding the
control of nosocomial infections:
1. Disinfection of inanimate reservoirs and vehicles of transmission
2. Antibiotic treatment of consumers and employees
3. Limitation of visitors that may be infected
4. Policies regarding ill employees
5. Secretion and excretion precautions
6. Hand washing between contact with consumers
7. Proper handling of specimens
8. Environmental sanitation, proper waste disposal and proper laundry practices
9. Nursing procedures that minimize exposure to body fluids that prevent
compromise in body defenses and that improve immunologic status for
consumers and employees
8.2 Community-Acquired Infections
A. Community-acquired infection: An infection that is contracted from a source outside of
the facility and is present at the time of admission.
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9. GENERAL METHODS OF PREVENTION AND CONTROL

9.1 Interventions/Methods to Reduce the Risk of Infection Transmission
A. Standard Blood and Bodily Fluid Precautions:
1. Simply referred to as "Standard Precautions", this strategy stresses that all
individuals should be assumed to be infectious for HIV and other blood-borne
infections.
2. Standard Precautions (Attachment 1) should be followed by all employees and
individuals served, when exposed to blood or any bodily fluid visibly
contaminated with blood. It is recommended that all bodily fluids be treated as
potentially hazardous.
3. "Exposure" is defined as a percutaneous injury (e.g., needle stick or other
penetrating puncture of the skin with a used needle or other item),
contamination of a mucous membrane (splatter/aerosols into eyes, nose, or
mouth), or significant contamination of an open wound or non-intact skin with
blood, semen, vaginal secretions or other body substances which contain visible
blood.
4. To minimize the risk of acquiring HIV and HBV during performance of job duties,
employees should be protected from exposure as circumstances dictate.
Protection can be achieved through adherence to work practices designed to
minimize or eliminate exposure and through use of personal protective
equipment (i.e., gloves, CPR mouthpiece, etc.), which provides a barrier between
the employee and the exposure source.
5. Standard Precautions shall be adopted, and in-services provided, to assure
adequate training and protection for employees, physicians, volunteers, and
other caregivers who might be exposed to blood and body fluids of individuals
served. Compliance with Standard Precautions will be monitored by the facility
Infection Control Officer.
B. Personal Protective Equipment
1. It is the responsibility of the Building Coordinator and facility Infection Control
Officer to ensure each location maintains a supply of latex gloves, a minimum of
one Spill Kit, a Personal Protection Kit or the inventory found in the Personal
Protection Kit, and several disposable CPR airway devices, with one-way valves to
prevent a victim's saliva or vomitus from entering the caregiver's mouth. It is
recommended that disposable CPR airway devices be stocked in areas where
emergency first aid is a possibility to reduce the chance of transmission of various
communicable diseases during CPR. These should also be included in all Center
vehicles.
2. Gloves Should be Worn:
a. Whenever you will be in contact with blood or bodily fluids
b. If you have cuts, open wounds or lesions on your hands and you will be
providing services directly to an individual
c. If you are doing therapies which require you to put your hands in an
individual's mouth
d. If you are changing bandages covering an individual's cuts or lesions
e. If the individual has uncovered cuts or lesions and you will be providing
services directly to the individual
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f. Any contact with strong chemical solutions

3. Disposable gloves must be discarded in the red biohazard disposal bag following
use. Gloves should be removed upon completion of the task and hands washed
following removal of gloves. If hand washing facilities are not immediately
available, alcohol-based hand sanitizer may be substituted. Alcohol-based hand
sanitizer may only be used if hands are not visibly soiled.
4. Disposable gloves should be made available in Tri-County vehicles for employee
use.
C. Diseases Transmitted Through Air-Borne Contamination
1. Encourage the use of tissues for coughing and sneezing.
2. Dispose of tissues in waste baskets with a plastic liner.
3. Encourage the practice of washing hands after using tissues.
4. Discourage the passing of cigarettes, cups, soft drinks, and eating utensils.
5. Maintain a distance from an individual who is observed to have a respiratory
illness.
D. Handwashing Techniques
1. Handwashing is the single most important means of preventing the spread of
infections. Frequent handwashing will ensure hands and fingernails are free of
potentially infectious material and will prevent the spread of infection to self and
others. See the Centers for Disease Control (CDC) Guidelines for Handwashing
(attachment#9). When handwashing facilities are not available, employees shall
use an alcohol-based hand sanitizer to prevent the spread of infections. When
hands are visibly soiled, they should only be washed with soap and water. Health
care personnel should avoid wearing artificial nails and keep natural nails less
than one quarter of an inch in length if they care for patients at high risk for
acquiring infections.
2. The use of gloves does not eliminate the need for hand hygiene. Likewise, the
use of hand hygiene does not eliminate the need for gloves.
3. Examples of when to wash hands with soap and water:
a. Before contact with each individual, his/her environment, and things
that come in contact with the individual.
b. After contact with each individual, his/her environment, and things that
come in contact with the individual.
c. After you go to the toilet.
d. When your hands are visibly soiled.
4. Examples of when to use alcohol-based hand sanitizer:
a. When you arrive at your assigned work area.
b. Prior to leaving your work unit.
c. Before and after eating.
d. Before and after feeding individual.
5. How to wash hands:
a. Remove rings and jewelry.
b. Wet hands under warm running water.
c. Keeping hands lower than elbows, apply antimicrobial soap.
d. Rub hands together vigorously using friction until a soapy lather appears
and continue for at least 20 seconds. Be sure to scrub between fingers,
under fingernails, and around the tops and palms of hands.
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e. Thoroughly rinse hands under running water.

f. Dry hands with a clean, disposable (or single use towel), being careful to
avoid touching the faucet handles or towel holder with clean hands.
g. Turn the faucet off using the towel as a barrier between your hands and
the faucet handle.
h. Use the towel to open the door and discard the used towel in the trash
can either before or after leaving the restroom.
i. Apply hand cream liberally after frequent hand washings.
6. DO NOT USE A COMMUNAL BAR OF SOAP (This may cause the spread of
infection).
E. Staph Infection/MRSA
1. In order to address the specific processes needed when an individual in PETC or
a Tri-County residential program is diagnosed with a staph infection or
Methicillin-Resistant Staphylococcus aureus (MRSA), handouts on the condition
(Attachment 10) and contact precautions (Attachment 11) are to be distributed
to employees assisting with an individual diagnosed with one of these disorders
at the time it is diagnosed. Additionally, a protocol for providing care and
reducing risk of infection in these cases (Attachment 12) should also be used.
10. DIRECTIVES & GUIDELINES TO PREVENT AND CONTROL THE TRANSMISSION OF INFECTION
Directives and guidelines are furnished within this plan which address the areas listed. If an employee is
faced with an infection control issue which is not addressed within this plan, the employee is urged to
contact the Infection Control Committee Chair/Center-wide Infection Control Officer and Risk Manager.
10.1 Assault
A. Tri-County Behavioral Healthcare employees and individuals participating in services are
sometimes exposed to a range of assaultive and disruptive behavior through which they
may potentially become exposed to blood or other body fluids containing blood.
Behaviors of particular concern are biting, attacks resulting in blood exposure, and
attacks with sharp objects.
B. Whenever the possibility for exposure exists, protection should be worn, if feasible
under the circumstances. In all cases, extreme caution must be used in dealing with
volatile individuals. When blood is present, and an individual is combative or
threatening to employee, protective gloves should be put on as soon as conditions
permit. In case of blood contamination of clothing, clothes should be changed as soon
as possible, and clothing should be placed in an identified or marked leak-proof plastic
bag. An Incident Report must be completed as soon as possible.
10.2 Management of Human Bites
A. An incident of a human bite shall be reported immediately to a supervisor and the
facility Infection Control Officer, and an Incident Report shall be completed. The facility
Infection Control Officer should also contact the Senior Human Resource Specialist of
the incident.
B. Action Steps:
1. The wound should be washed immediately for a minimum of five (5) minutes with
warm soapy water.
2. Tetanus vaccination status should be evaluated, since bites frequently result in
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infection with organisms other than HIV and HBV. If immunization records reveal
that tetanus status is questionable (over 10 years), the attending physician may
recommend a tetanus shot.
3. Victims of bites should also be evaluated for exposure to blood or other infectious
body fluids.
4. Complete the Incident Report form as soon as possible.
10.3 Needles and Syringes and Incidents of Needle-Stick
A. Safety Syringes
1. All medical personnel are expected to use extreme caution when handling
needles and syringes.
2. Handwashing is mandated prior to beginning the procedure of giving an injection
or drawing blood, and again before providing care to another patient.
3. Only safety syringes are permitted for use in Tri-County Behavioral Healthcare
facilities.
4. Used syringes, as well as soiled alcohol preps and Band-Aids, shall be disposed of
in an approved puncture-resistant, leak-proof, container labeled “sharps
container”.
a. The container should be located as close as practical to the work area.
Needles in the sharps container shall not be capped or bent.
b. The box must be secured (locked/closed) and disposed of when no
greater than 2/3 full, or after 30 days of use.
c. The boxes should be marked with a permanent marker, with an
expiration date noted to guarantee timely disposal in areas of
infrequent use.
d. Used needles and syringes are defined by the Texas Department of
Health (TDH) and the Occupational Safety and Health Administration
(OSHA) as biohazard waste, requiring special handling, treatment, and
disposal.
e. Employee shall be able to accurately describe the policy for handling a
full sharps container.
B. Incidents of Needle-Stick - If an employee suffers a needle-stick, sharps injury, or was
exposed to the blood or other body fluid of a patient during the course of your work,
immediately follow the following steps:
1. Wash needle-sticks and cuts with soap and water.
2. Flush splashes to the nose, mouth, or skin with water. Irrigate eyes with clean
water, saline, or sterile irrigants. No scientific evidence shows that using
antiseptics or squeezing the wound will reduce the risk of transmission of a blood
borne pathogen. Using a caustic agent, such as bleach, is not recommended.
3. Report the incident to your supervisor immediately, who will then direct exposed
individual to the facility Infection Control Officer.
4. An Incident Report must be completed (Attachment 13).
5. Facility Infection Control Officer will notify the Senior Human Resource Specialist
of the incident.
6. Follow-up testing for any exposed employee is necessary to determine if the
exposure resulted in transmission of a bloodborne disease.
7. At the time of the exposure, the employee will be referred to the Urgent Care or
local emergency room for appropriate treatment.
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8. Incidents of contaminated (used) needle stick injuries require the submission of

a Contaminated Sharps Injury Reporting Form (Attachment 14), as required by
the Texas Department of State Health Service.
a. This form should be completed no later than 10 working business days
after the incident occurs.
b. Completed forms shall be provided to the Infection Control Committee
Chair/Center-wide Infection Control Officer.
9. Preventative practice should include effective education, monitoring compliance,
assistance, retraining if necessary, and disciplinary action towards those who
repeatedly fail to follow the recommended guidelines as presented.
C. Sharps Injury Log
1. The employer shall establish and maintain a sharps injury log to record
percutaneous injuries from contaminated sharps. The sharps injury log must
include dates, times, and related incident information as mandated by law. The
information in the sharps injury log shall be recorded and maintained in such a
manner as to protect the confidentiality of the injured employee. The sharps
injury log will contain, at a minimum:
a. The type and brand of device involved in the incident.
b. The department or work area where the exposure incident occurred.
c. The explanation of how the incident occurred.
D. Potential Exposure to HIV
1. Review the individual’s chart to see if lab work on infectious agents has been
done. The individual may be asked to agree to be tested for hepatitis and HIV,
and if they agree, testing will be done at Tri-County Behavioral Healthcare’s
expense utilizing the contracted lab service.
a. The Infection Control Committee will review of the frequency of needle
stick injuries and may recommend to develop a protocol for testing of
an individual who may have exposed employee to HIV without the
person’s specific consent to the test, as per Texas Health and Safety
Code (§81.105 & §81.106). Such a protocol must ensure:
i. The test is done according to protocols established by Section
81.102(c) of the Texas Health and Safety Code; and
ii. Such protocols ensure that any identifying information
concerning the individual tested will be destroyed as soon as the
testing is complete, and the individual who may have been
exposed is notified of the result.
iii. A test result under this section is subject to the confidentiality
provisions of this chapter.
iv. Protocols must clearly establish procedural guidelines with
criteria for testing that respect the rights of the person with the
infection and the individual who may be exposed to that
infection. The protocols may not require the individual who may
have been exposed to be tested and must ensure the
confidentiality of the individual with the infection in accordance
with this chapter.
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10.4 Thermometer Care

A. Thermometers are often used for more than one individual. This represents a risk for
transmission of infection and cross contamination. Special care shall be taken to
prevent the carriage of infection.
1. Care should be taken to use only oral thermometers orally, and rectal
thermometers rectally. The two shall never be used interchangeably.
2. A fresh probe cover must be applied for each individual use and discarded in a
plastic lined waste receptacle. The probe cover is contaminated after use, and
must not be touched with the hands.
3. After discarding the contaminated probe cover, the thermometer shall be
disinfected with a 70% alcohol sponge.
4. Hands must be washed after taking an individual's temperature, discarding the
contaminated probe cover, and disinfecting the instrument.
10.5 Decontaminating Mannequins Used in CPR Training
A. Purchasers of training mannequins should thoroughly examine the manufacturers'
recommendations and provisions for sanitary practices.
B. Employees should be told in advance that the training sessions will involve "close
physical contact" with their fellow employees.
C. Employees should not actively participate in training sessions (hands-on training with
mannequins) if they have dermatologic lesions on hands, or in oral or circumoral areas,
or if the employee has reason to believe that he or she has been exposed to or is in the
active stage of any infectious process.
D. All employees responsible for CPR training should be thoroughly familiar with hygienic
concepts (e.g., thorough handwashing prior to manikin contact, not eating during class
to avoid contamination of mannequins with food particles, etc.), as well as the
procedures for cleaning and maintaining mannequins and accessories (e.g., face
shields). Mannequins should be inspected routinely for signs of physical deterioration,
such as cracks or tears in plastic surfaces, which make thorough cleaning difficult or
impossible.
E. At the end of each class, the procedures listed below should be followed as soon as
possible to avoid drying of contamination on mannequin surfaces:
1. As indicated, thoroughly wash all external surfaces of the mannequin with Clorox
wipes.
2. Training area, to include tables and mats, will be disinfected by the CPR trainers
after each use using a mixture of Lysol and water.
F. Each time a different employee uses the mannequin in a training class, the individual
protective face shield, if used, should be changed. Between employees or after the
instructor demonstrates a procedure such as clearing any obstruction from the airway,
the mannequin’s face and inside the mouth should be cleaned with Clorox wipes.
10.6 Pet Vaccinations
A. With the exception of service animals, all pets on facility premises shall have current
vaccinations and determined by a veterinarian to be in good health at the time of such
vaccinations. All veterinary records shall be maintained in the facility's Infection Control
records.
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10.7 Re-use of Disposable Items

A. The re-use of disposable items such as needles, syringes, plastic gloves, airway devices,
etc. is strictly prohibited. Under no circumstances are disposable items to be
reprocessed for additional use.
10.8 The Storage and Quality Control of Sterile Equipment and Medical Supplies
A. Commercially prepared sterile items such as disposable needles/syringes, alcohol preps,
disposable airway devices, etc. shall be stored separately from medications or chemicals
in a dry, clean storage unit at least six (6) inches above the floor.
B. Prior to using a pre-packaged sterile item, the packaging shall be inspected to ensure
package integrity and lack of contamination. If commercially prepared items labeled by
the manufacturer as “sterile” do not specify an expiration date, they must be dated
upon receipt. Sterile items that do not have a specified expiration date shall be disposed
of and replaced if not used within 12 months of receipt in order to ensure a sterile state.
10.9 Toys - Procedures for Cleaning and Disinfecting Environmental Surfaces
A. Studies have shown that viruses, including HIV virus, are rapidly inactivated after being
exposed to commonly used chemical germicides at concentrations that are much lower
than used in practice. Either commercially available germicides approved by the
Environmental Protection Agency (EPA) or a diluted solution of household bleach
prepared daily are acceptable for routine disinfection procedures.
1. Cleaning surfaces of mats and play areas:
a. Support staff will scrub mats, tables, and play surfaces under normal use
with a soap and water, chlorine bleach, or with a germicidal cleaning
solution at least once daily. The actual physical removal of micro-
organisms by scrubbing is probably at least as important as any
antimicrobial effect of the cleaning agent used.
b. Support staff will wipe surfaces with a solution of chlorine bleach or
germicide. Germicidal solutions can be dispensed conveniently with
spray bottles. Rinse the surfaces thoroughly and allow to dry.
c. Support staff will clean mats and play surfaces immediately upon
contamination with blood or body fluids.
2. Cleaning Toys:
a. Toys kept in any Tri-County buildings will be cleaned daily by support
staff using a 1:10 mixture of bleach and water, or with an EPA approved
germicidal solution. Broken or worn toys that pose a health risk to
children will be discarded. Toys that are made of a material that cannot
be disinfected will be removed from common areas. Toys will be
cleaned immediately upon contamination with blood or bodily fluids.
10.10 Disposal of Infectious Waste
A. The most practical approach to the management of infectious waste is to identify those
wastes with the potential for causing infection during handling and disposal, and for
which some special precautions appear prudent. Wastes for which special precautions
appear prudent includes any items that has had contact with blood or body secretions.
B. At this time, federal regulations do not define infectious waste as hazardous waste;
however, infectious waste falls into the special handling category, as there are special
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recognized occupational exposure issues that must be dealt with.

C. Needles and syringes, soiled wound dressings, soiled latex gloves, other blood-
contaminated items, soiled diapers, or other materials soaked with various body
secretions such as vomitus, shall be considered infectious waste, and shall require
special handling procedures.
D. Action Steps:
1. Employees must wear latex or plastic gloves when handling infectious or
potentially infectious waste.
2. Needles and syringes, soiled alcohol preps and Band-Aids shall be placed in a
puncture-proof container for pick-up, transport, and incineration by a contracted
medical waste management company.
3. Other blood-contaminated items, such as soiled wound dressings shall be placed
in red leak-proof plastic biohazard bags. Biohazard bags shall be securely sealed
(twist tie, tape, or tied in a knot), and placed in an appropriate biohazard
container.
E. Medical waste pick-up is scheduled every month at medication clinics. When a pick-up is
made, copy of the Regulated Medical Waste Manifest will be left at the office. The
manifest should be forwarded to the facility Infection Control Officer. Extra biohazard
bags can be ordered through Stericycle. All other containers are ordered form
McKesson Medical Supplies.
F. Currently, Stericycle, Inc. is contracted as Tri-County’s biohazardous waste management
company.
Contact: Nikalay Kanagin

Phone: (847) 943-6789
Fax: 1-866-241-0056
10.11 Cleaning and Decontaminating After Blood Spills
A. All spills of blood and blood-contaminated fluids should be promptly cleaned up using
an EPA-approved germicide, or a 1:100 (1 part to 100 parts) solution of household
bleach. WHILE WEARING DISPOSABLE GLOVES, visible material should first be removed
with disposable towels or other appropriate means that will ensure against direct
contact with blood. If splashing is anticipated, protective eye wear shall be worn along
with a plastic gown which provides an effective barrier to splashes. The area should
then be decontaminated with an appropriate germicide.
B. Soiled cleaning equipment (i.e., mops) should be cleaned and decontaminated, or
disposed of in labeled, red, leak-proof biohazard bags. Labeled leak-proof plastic bags
shall be available for removal of contaminated items from the site of the spill.
C. Shoes may become contaminated with blood in certain instances. Clean-up should not
occur until the individual cleaning up the spill has obtained disposable plastic shoe
coverings or is willing to dispose of the shoes which he/she is wearing.
D. Once the area has been cleaned and decontaminated, and all exposed clothing and
cleaning equipment has been taken care of, the individual may remove the disposable
gloves and must thoroughly wash hands.
10.12 Lab Specimen and Storage
A. Lab specimens shall be collected upon a physician’s order utilizing Standard Precautions.
B. Lab specimens awaiting laboratory pickup shall be stored in the unit specified area. In
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no instance may specimens be left on the nursing station work area, in the medication
room, or near a food service area.
10.13 Care of Individual's Personal Needs and Items
A. Individuals (residential and non-residential) who maintain personal items, such as a
toothbrush or feminine hygiene products, shall be provided a clean, secure place to
store such items. Personal items shall be stored in plastic containers and labeled with
the individual's name in order to avoid accidental contamination. In the event that an
incontinent individual voids or soils clothing or bedding, or a continent individual has a
toileting accident, all soiled items shall be changed immediately, and the individual shall
be cleaned immediately.
B. Stool shall be discarded in a commode. Wearing plastic gloves, unit personnel shall pre-
wash or pre-rinse linens or clothing, place in a plastic bag, and tie securely.
C. In residential facilities, contaminated clothing is to be placed directly into the washing
machine so that contamination does not permeate the rest of the laundry. In non-
residential facilities, a plastic bag containing pre-rinsed clothing shall be sent home with
the individual.
10.14 Precautionary Measures and Monitoring for Possible Outbreak of Bedbugs in PETC and IDD
Residential Programs
A. All new employees will be trained on identifying the signs and symptoms of bedbug
bites and will be familiar with environmental signs of a possible bedbug infestation that
would signal an outbreak.
B. To minimize the possibility of a bedbug outbreak, employee designated by the program
director as responsible for cleaning will ensure a clean and sanitary environment.
Employee will inspect and monitor for signs of bedbugs on bedding, furniture, patient
belongings, and surfaces on an ongoing basis.
C. As part of this inspection, employee will inspect the home for cracks in wood surfaces or
walls, furniture in poor condition needing repair or replacement including tears in fabric
or cracked wood, signs of bedbugs around baseboards, nightstands, mattresses, box
springs, wooden/fabric bedframes, couches, and chairs. If the employee or program
director notes furniture that needs to be replaced, they will requisition bedbug resistant
replacement items if possible.
D. At the discretion of each program director, mattress covers designed for bedbug
prevention will be placed on each mattress and each box spring. When possible, older or
damaged furniture and fixtures will be replaced by bedbug resistant alternatives such as
metal, faux leather, or tile.
E. Where available and practical, clothing items brought in by patients on admission will be
dried on high heat (over 120 degrees) for 2 minutes.
10.15 Management of Suspected Bedbugs in PETC and IDD Residential Programs
A. Direct care employees will monitor individuals for possible bedbug bites. Should any
direct care employee, including contracted employee, suspect that a patient has been
bitten by a bedbug:
1. The direct care employee will immediately notify the nurse on call or on site. The
LVN or RN will assess patient for possible bites and notify the director of the
residential program if bed bugs are suspected.
2. The program director, or their designee, will examine the location for signs of
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bedbugs.
3. Take the person’s room out of service for other patients/residents until inspected
and cleaned and treated.
B. If it is confirmed that an individual has been bitten by a bedbug:
1. The nurse on call or on-site will notify the individual’s treating physician or
designee for treatment orders.
2. Healthcare workers should only wear PPE as needed for Standard Precautions
(protection against contact with body fluids/substances during care activities).
Additional PPE is not recommended (e.g., gowns and gloves for casual contact).
Shoe covers and hair coverings are not recommended.
3. Contain all non-essential individual/resident belongings in plastic bags; double-
bag and seal each bag. This includes clothing, shoes, luggage, and personal
electronics.
4. Inspect the individual’s essential personal belongings, equipment, and devices
brought into the healthcare setting. For example, bedbugs may be present on or
in wheelchairs/cushions, sheepskins, splints and/or heat-producing equipment
such as O2 compressors.
5. Arrange for the individual’s clothing to be laundered in hot water (at least 120F)
and dried on a hot setting or dry-cleaned. Bed bugs can be killed in less than a
minute or two by heat over 120 degrees. If laundering clothes in hot water is not
possible, check with local dry cleaners for special laundering abilities, if you
cannot wash them.
6. Inspect crevices of articles brought into the health care setting, including
equipment, bags, shoes, and clothing, BEFORE leaving the area.
7. The LVN or RN will complete an Incident Report Form to be submitted to the
Infection Control Committee Chair/Center-wide Infection Control Officer.
C. When it has been determined that a bedbug outbreak has occurred at a residential
location, the program director will contact the contracted pest extermination agency to
treat infestation. The exterminator will continue to spray the residential facility as per
current guidelines. Employee will continue to monitor for signs of activity in each
location where an outbreak has been detected, and will:
1. Remove all clutter from the infested room. This includes clothing, books,
magazines, storage containers, and other such items.
2. Move furniture away from walls.
3. Bag, remove, and launder all sheets, covers, pillowcases, stuffed animals, and
clothes in the infested room. Wash and dry these articles on high heat. Do not
replace these items in the infested room until the pest has been controlled.
Ideally, store these items in a sealed bag in a separate room. Consider using a
commercial dry-cleaning service to handle difficult or unique laundering
problems.
4. Vacuum entire floor, baseboards, mattresses, bed frames, nightstands, furniture
and other cracks and crevices in the infested room. Discard or empty the
containers into a plastic bag then seal it and place it outdoors in garbage
container.
5. Consider using forced air to clean computer equipment and electronics items that
may be more difficult to clean. Cans of compressed air are typically available at
office supply stores and electronics stores.
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6. Program director will consult a licensed pest control operator for treating items
that cannot be sent to laundry (e.g., wheelchair cushions, personal mobility aids).
7. Following treatment to eradicate the infestation by the pest control operator,
clean the area where pesticides are applied as recommended by the pest control
operator. The remainder of the room/area is to be cleaned as per usual room
cleaning protocols or procedures. Additional disinfectants or pesticides are not
recommended.
11. SURVEILLANCE OF INFECTIONS

The surveillance of infection will monitor the effects of intervention strategies on infection rates and
provide valid measures of the risk of infection among individuals/residents receiving services. Surveillance
often results in action to reduce those risks and decrease infection rates.
The Infection Control Committee and Management Team shall approve actions to prevent or control
infection based on an evaluation of surveillance reports of infections and of the infection potential among
individuals receiving services and organization personnel.
The Infection Control Committee shall provide feedback to selected physicians, nurses, and support
employee, when appropriate and pertinent, about infection risk of the individuals under their care who
reside in residential facilities.
11.1 Reporting and Documenting Employee Illnesses
A. Employees are prohibited from working at Tri-County Behavioral Healthcare during the
communicable phase of an infectious disease or illness. The Director of Nursing makes
the determination if it is the best interest of the individual and others at risk of infection
to be restricted from work or programming.
B. Immediately upon recognition or diagnosis of a potential or confirmed communicable
disease or infection, employees are required to report to their immediate supervisor.
Employees dismissed from direct care duties due to the presence of infectious illness may
utilize accrued Paid Time Off (PT) per HR policy. Employees must be symptom free for at
least twenty-four hours before returning to Tri-County.
C. Symptoms of potential infectious illness include, but are not limited to:
1. Fever (above 100.5F)
2. Vomiting
3. Diarrhea
4. Hemoptysis (bloody cough)
5. Open Wound(s)
6. Infestation (e.g., lice or bedbugs)
11.2 Reporting and Documenting Patient Illness
A. Each employee is responsible for the timely reporting of communicable diseases or
infections reported by or observed in individuals receiving services. All communicable
diseases shall be reported to the designated facility Infection Control Officer.
11.3 Identification of Illnesses which may Allow Continuation or Exclusions from Tri-County
Behavioral Healthcare Programs
A. Attachment 15 contains a list of communicable diseases which may allow or prohibit
individuals from continuing to participate in Tri-County Behavioral Healthcare programs.
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1. Illnesses That Will Require Transfer from Residential Facilities

a. Because Tri-County Behavioral Healthcare does not offer negative air
flow rooms in any of its facilities, all cases of active or infectious
tuberculosis shall be transferred to the nearest available facility.
b. The advice and recommendation of the individual's primary care
physician will be considered for other illnesses. The following
conditions shall be evaluated and documented prior to transfer to
another placement:
i. The primary care physician feels the illness can best be treated in
a hospital or other health care facility.
ii. The primary care physician feels the illness endangers the health
status of "high risk" individuals, for example, an individual with
decreased resistance (i.e., AIDS) or other immunological
deficiency that also receives service in the facility.
iii. The primary care physician feels the health status of
employee/providers working at the facility is jeopardized.
2. Short-Term Transfer Plan - Residential Facilities
a. For individuals requiring temporary transfer to a hospital or
convalescent facility, the following process will occur:
i. The transfer will be made in a private vehicle, or arrangements
will be made for ambulance transfer.
ii. With appropriate consent, the facility's nurse will be responsible
for providing the individual's medical information to the
hospital/facility employee.
iii. The individual's Case Manager or Social Worker will notify the
legal guardian or family, and any other pertinent individuals
required by program standards.
iv. The facility's nurse shall follow the individual's treatment and
convalescence and arrange for return to facility when the
individual is released by his or her primary physician.
3. Isolation Procedures for Those Not Transferred - Residential Facilities
a. Although Standard Precautions are to be used for all individuals,
application of protective measures will vary as the need arises for each
situation. Guidelines for appropriate use of protective apparel are given,
and other related procedures are referred to in the various sections of
the Infection Control Plan.
b. It is not necessary to use additional isolation or restrictive measures for
chronic carriers, or individuals harboring blood borne disease such as
Hepatitis B, C, or HIV infection unless otherwise specified by the treating
physician. If an individual routinely or repeatedly exposes others to his
or her body substances, then there is cause for concern. The problem
shall be brought to the attention of the primary treating physician and
facility Infection Control Officer. Certain restrictive or isolation measures
may need to be applied in this scenario.
c. The facility Infection Control Officer shall always be notified whenever
standard isolation measures are considered. Consultation should also be
obtained prior to the initiation of any new infectious restrictive measures
20
that are taken, including the transfer of individual to a hospital or nursing

facility as a means of isolating or treating an infectious disease. Isolation
measures must always comply with federal and state standards and fall
within the guidelines of the CDC.
d. In certain situations, and also in accordance with CDC, prompt
recognition of outbreaks, combined with cohorting of symptomatic
individuals may reduce the spread of infectious disease. Cohorting is
placement of individuals who have a common infectious disease together
in a setting that is conducive to their well-being. An example of effective
cohorting is allowing two or more residential patients with active measles
or chicken pox to live and play together, supervised by employee
members who are immune to the infection. Cohorting, when feasible,
shall always be initiated and performed under the direction of primary
treating physician or the Infection Control Officer.
e. Guidelines for the management of patients with serious infections in IDD
residential units are outlined in (attachment #12).
11.4 Documenting Potential Infection Control Issues
A. Infection Surveillance Log and Infection Control Summary of Activities
1. At the earliest opportunity, it is required that each employee report to the facility
Infection Control Officer any reported or observed communicable diseases or
infections. The facility Infection Control Officer shall log the report on the
Quarterly Infection Surveillance Log (Attachment 16), review the individual's
chart, if indicated, and interview the individual and unit employee to determine
if the infection is nosocomial or community acquired.
2. The facility Infection Control Officer shall log the date reported, name, and case
number of the individual whether the individual is a patient/resident, or an
employee, the suspected or reported illness or infection, whether the infection is
community-acquired or nosocomial, treatment received (if any),
recommendation to the individual (i.e., see family physician, sent home until no
longer communicable, etc.), and primary service provider or employee's unit.
3. The facility Infection Control Officer shall submit the Surveillance Log/ Summary
by the tenth (10th) working day of the month following the end of each quarter
in which an infectious illness was reported. The Facility Infection Control Officer
shall maintain the original in the facility's Infection Control records and submit a
copy to the Infection Control Committee Chair/Center-wide Infection Control
Officer.
4. IN ORDER TO PROTECT CONFIDENTIALITY, KNOWN CASES OF HIV OR AIDS VIRUS
ARE NOT TO BE DOCUMENTED ON THE INFECTION LOG.
11.5 Reviewing Infection Control Data
A. Infection Rates Assessment of Surveillance or Intervention Methodology Which Has
Proven Ineffective in Reducing Rate of Infection
1. In the event that surveillance methods, prevention and control interventions, or
feedback to pertinent personnel within the organization have not reduced the
rate of infection, the Infection Control Committee Chair/Center-wide Infection
Control Officer shall report to the Infection Control Committee to investigate and
address these concerns.
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2. The Infection Control Committee may recommend innovative educational

approaches beyond the routine or standard employee training. The Infection
Control Committee may also enlist the assistance of key management personnel
to implement activities aimed at changing attitudes and behaviors concerning
infection control. The Infection Control Committee may recommend systems
changes such as staffing, control of overcrowding, or the lack of proper
equipment and supplies.
B. Annual Evaluation of the Infection Control Plan
1. The Center will complete an annual evaluation of the infection prevention and
control plan each year and whenever its priority risk significantly changes which
will include but not limited to: The infection and control priority risk, infection
prevention and control goals, implementation of the infection prevention and
control plan’s activities.
12. POST-EXPOSURE MANAGEMENT OF CHRONIC STATE INFECTIONS (HIV, HBV, AND TB)
“Exposure” is defined as a percutaneous injury (e.g., needle stick or other penetrating puncture of the
skin with a used needle or other item) or contamination of a mucous membrane, (splatter/aerosols into
eyes, nose, or mouth) or significant contamination of an open wound or non-intact skin with blood,
semen, vaginal secretions or other body substances which contain visible blood.
All such exposures to blood and body substances which meet the foregoing criteria must be reported
promptly (within 1 hour) to the employee's supervisor and the facility Infection Control Officer. If an
employee working in a residential setting contracts a communicable disease that is transmissible to
consumers through food handling or direct consumer care, the employee shall be excluded from providing
these services as long as a period of communicability is present.
12.1 Post Exposure Management for TB
A. Should an employee report recent exposure to any individual with active TB, they are to
notify their direct supervisor immediately. The direct supervisor should contact the
facility Infection Control Officer who will follow the below steps:
1. Obtain details on the recent exposure.
2. Contact Risk Management (Incident Report completed upon request by Risk
Management)
3. Provide TB Skin Test (If employee unable to tolerate skin test, contact Tri-County
Integrated Medical Doctor for chest x-ray order.
12.2 Post Exposure Management for HepB
A. Should an employee report recent exposure to any individual found to be positive for
Hepatitis B, they are to notify their direct supervisor immediately. The direct supervisor
should contact the facility Infection Control Officer who will follow the below steps:
1. Obtain details on the recent exposure
2. Contact Risk Management
3. Have employee complete Incident Report
B. The employee shall receive the hepatitis B vaccine series. A single dose of hepatitis B
immune globulin (HBIG) is also recommended if received within seven days of exposure.
If the individual has previously received vaccine, the exposed individual shall be tested for
antibody to hepatitis B surface antigen (anti-Hbs) and given one dose of vaccine and one
dose of HBIG if the antibody level in the individual's blood sample is inadequate.
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C. If the source of the exposure refuses testing, or he/she cannot be identified, the
unvaccinated individual shall receive the hepatitis B vaccine series.
12.3 Post Exposure Management for HIV
A. The risk of HIV infection following accidental/occupational exposure is extremely low.
Ten years of studies of all reported percutaneous exposures indicate a 0.3% (one-third of
one percent) overall risk of infection. The risk is highest with:
1. A deep injury;
2. Gross blood on the device causing the injury;
3. A device previously placed in the patient’s vein or artery;
4. A source patient with a high titer of HIV.
B. The overall risk of infection following a mucocutaneous exposure is approximately 0.1%
and exposure to non-intact skin is <0.1% (the infectivity rate increases with the amount
of blood, HIV titer and exposure duration).
C. Guidelines for suspected exposure to HIV through accidental needle stick injury are
included in Directives and Guidelines to Prevent and Control the Transmission of Infection
section of this policy.
13. MANAGEMENT OF EMPLOYEES OR INDIVIDUALS WITH HIV AND HBV

Individuals with impaired immune systems resulting from HIV infection or other causes are at increased
risk of acquiring or experiencing serious complications of infectious disease. Of particular concern is the
risk of severe infection following exposure to other persons with infectious diseases that are easily
transmitted if appropriate precautions are not taken (e.g., measles).
Any individual with an impaired immune system should be counseled about the potential risk associated
with providing care to persons with any transmissible infection and should continue to follow existing
recommendations for infection control to minimize risk of exposure to other infectious agents. Individuals
should consider vaccination with live-virus vaccine (e.g., measles, rubella).
Individuals who wish to be screened for HIV will be referred to alternate counseling and testing sites within
the community. All employees, as indicated in their job descriptions, are expected to perform their duties
including providing care for consumers with communicable diseases, one of which is HIV/AIDS.
Employees who refuse to work with individuals or with other employees who have HIV infection or who
exhibit discriminatory behavior toward these individuals may be considered insubordinate. Their actions
shall be evaluated and dealt with by their direct supervisor. All employees, including those with HIV
infection, shall be hired and/or retained in their jobs based on their ability to perform the job adequately
and safely.
13.1 Limitation of Activities for Patients
A. Whether an individual receiving services who is infected with HIV can safely remain in
current services, or whether the induvial treatment plan should be modified, shall be
determined on a case by case basis. These decisions shall be made by the individual's
personal physician(s) in conjunction with the treatment team members, and Tri-County
Behavioral Healthcare Medical Director.
B. The behavior and medical considerations of each individual will be evaluated by the
attending physician with appropriate consultation, and only those restrictions recognized
to be necessary relative to containment of infection in each particular case will be
imposed.
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1. Individual cases shall be thoroughly reviewed by the physician in consultation

with appropriate members of the interdisciplinary team in accordance with the
Texas Health and Safety Code regarding confidentiality of the information. The
reviews will be at intervals specified in the individual treatment plan or when
there are significant changes in the individual's behaviors which might affect the
individual's potential for infecting other patients or employee. If risk potential is
established, the least restrictive intervention shall be implemented by the
interdisciplinary/ treatment team to ensure the safety of other individuals and
employee.
2. Individuals who are too ill medically to benefit from services shall be expeditiously
referred to an appropriate medical facility.
13.2 Employees with HIV or AIDS
A. The question of whether an employee infected with HIV can adequately and safely be
allowed to perform direct care duties, or whether their work assignments should be
changed, must be determined on an individual basis. These decisions should be made by
the individual's personal physician(s) in conjunction with Tri-County Behavioral
Healthcare Medical Director.
14. DIETARY
Tri-County will maintain a sanitary environment and will avoid sources and/or practices that would result
in transmission of infections. The practices will comply with city, county and state health department
regulations and DSHS/DADS standards.
14.1 Personnel Handling Food for Individuals
A. All employees serving food will be free of active or communicable diseases such as skin
lesions/infections, boils, upper respiratory infections, enteric diseases, or any other
disease that will post a hazard to others.
B. All employees will always use good hand hygiene techniques as listed previously.
C. No unauthorized persons are allowed in the food preparation area.
14.2 Food Preparation
A. Most foodborne disease outbreaks caused by bacteria result from food stored at
improper holding temperatures. Poor personal hygiene practices, on the part of the food
handler, are usually the cause of foodborne disease outbreaks caused by a virus. All
employees preparing food for clients will be aware that certain employee practices
contribute to food borne disease. These practices include:
1. Poor personal hygiene by food handlers
2. Improper holding temperature of food
3. Inadequate cooking of food
4. Using food from an unknown source
B. A separate work area will be assigned for the preparation of cold foods and hot foods. All
preparation areas must be clean to prevent cross contamination.
C. Before using raw fruits and/or vegetables, they must be washed under running water in
a clean container.
D. Cooked food must reach a temperature throughout of at least 74 degrees centigrade (165
degrees Fahrenheit). Hot food must be held at 60 degrees Centigrade (140 degrees
24
Fahrenheit).
E. All foods must be kept covered between the time of preparation and the time of serving.
F. Hot and cold foods shall be served as soon as possible after preparation. Food cooked
but not served can be stored in the refrigerator in a covered container that is labeled and
dated. The leftover food must be eaten within three days or less. Leftover foods to be
served hot should be reheated to a minimum temperature of 105 degrees F.
G. Food shall be prepared with the least possible hand contact. Gloves will be worn by all
employees whenever there is direct contact with any food when serving food.
H. Separate cutting boards must be used when cutting raw meat and vegetables. Each board
will be identified as to its use and washed thoroughly after each use. Cutting boards will
be of impervious white plastic materials, not wood. Prepared foods will not be cut on
same boards as raw foods.
I. Food in broken packages or swollen cans or with any abnormal appearance or odor will
be destroyed.
J. Ice stored for dispensing shall be free from contamination and shall not have food or
anything else stored directly in it. Ice will not be scooped by hand. The ice scoop will be
washed on a regular basis and kept in a clean container near the ice machine when not in
use.
K. All dietary supplies will be clearly labeled.
L. No cleaning supplies or other non-food items will be stored with food supplies.
M. Employees shall inspect all new food products as they arrive for damage, rodent or insect
infestation or spoilage.
N. All can openers must be cleaned daily.
O. In dishwashing machines, all dishes must be washed in water at a temperature of 60
degrees Centigrade (140 degrees Fahrenheit) for 20 seconds minimum and rinsed at a
minimum temperature of 82 degrees C. (180 degrees F) for 10 seconds minimum. When
dishes are washed manually, they shall be washed in water at a temperature of 43.5-49
degrees C. (110-120 degrees F.) with an adequate amount of soap or detergent and then
sanitized at 76.5 degrees C. (170 degrees F.) for at least half a minute in a solution
containing an effective sanitizing agent.
P. Arrangements and cleaning procedures for food storage areas, to prevent contamination
of food shall be in compliance with local health department regulations. A copy of all
health department inspections shall be sent to the chairperson of safety committee. All
food purchased shall be from sources approved or considered satisfactory by the
appropriate health authority.
Q. Food storage refrigerators and freezers shall be provided with thermometers to give
assurance that foods are kept at appropriate temperatures. The ideal ranges are as
follows:
1. Fruits and vegetables, dairy products, meat and poultry at temperatures from 7C
(45 F) to 0.5 C (33 F); and
2. Fish, ice cream, and frozen foods at temperatures from below freezing to –23.5 X
(-10 F).
3. Frozen foods that have been thawed shall not be refrozen but shall be used
immediately. Wet storage of packaged foods is strictly prohibited, and home
canned foods shall not be used. Lighting, ventilation, and humidity shall be
controlled to prevent condensation of moisture and growth of molds.
R. Shelf space for all foods shall be provided with a floor clearance of six (6) inches to permit
25
proper floor cleaning. All non-food items shall be properly labeled and stored away from
food products.
S. Refrigerators and freezers should also be kept clean and well maintained in order to
properly maintain temperature.
T. Plastic-ware or china that has lost its glaze or is chopped or cracked shall be disposed of
to prevent further use. Disposable containers and utensils shall be discarded after one
(1) use.
U. Food grinders, choppers, mixers, etc., shall be properly cleaned, sanitized and dried after
each use.
V. After each period of use, there shall be a thorough cleansing and sanitizing of all dietary
work areas and surfaces.
W. Food wastes must be disposed of in leak proof and non-absorbent containers with close
fitting lids. All such garbage containers shall be removed on a daily basis, cleaned and
sanitized. Non-food waste shall be in containers with plastic liners.
X. Individual portions of food not consumed by an individual shall be discarded.
Y. Hot and cold-water pipes, water heaters, refrigerators, compressors, condensing units
and uncontrolled heat-producing equipment shall be properly insulated.
15. GENERAL HOUSEKEEPING

Cleaning procedures conducted in all Tri-County units shall be in accordance with the Infection Control
Manual. This manual will be reviewed and revised as needed on an annual basis. A copy of this manual
shall be accessible by all Tri-County employees. This manual establishes uniform standards for the
cleaning procedures at Tri-County.
A. Procedure:
1. All trash receptacles will be emptied daily.
2. Trash will be neatly bagged and taken to the garbage collection area for pickup.
3. All contaminated waste will be handled according to procedures located in this
manual.
4. Waiting room furniture and appliances will be cleaned daily as needed.
5. Furniture will be moved and cleaned underneath periodically as time allows.
6. All interior glass panels will be spot washed to remove handprints daily.
7. All drinking fountains will be cleaned, disinfected and polished daily.
8. All entrance doors, glass, mats, and thresholds will be cleaned weekly.
9. All housekeeping chemicals and supplies will be safely stored in a locked room.
10. Restrooms will be cleaned, disinfected and deodorized daily as follows:
11. Floors will be mopped and rinsed, using a mopping solution with disinfectant.
12. Commodes, urinals and wash basins will be scoured and disinfected daily.
13. Steel partitions and tile walls will be cleaned and disinfected as needed and/or
weekly.
14. Urinal and commode traps will be specifically cleaned as needed.
15. All hard surface floors will be maintained as follows:
16. A treated sweeping dust mop will be used daily.
17. Floors will be mopped with clean water and disinfected daily.
18. All spills will be immediately mopped up.
19. Floors will be mopped with a detergent solution.
20. A non-slip floor finish will be used to touch up heavy traffic areas.
26
21. Any spills containing body fluids will be handled according to contaminated waste
procedures located in this manual.
B. CSU Cleaning Procedure:
1. The CSU is cleaned six times a week by a commercial cleaning service.
2. The cleaning services must meet or exceeds all the cleaning requirements
included in this manual.
C. Clean Linen Procedures – Residential Units:
1. Clean linen is ordered from and delivered by the linen service on contract. Items
delivered include towels, washcloths, sheets, pillowcases, mattress pads,
bedspreads, and thermal blankets.
2. Linen is delivered and dirty linen picked up on a regular basis at least two times
weekly.
3. Clean linen is stored in a clean linen closet on shelves behind a locked door. This
linen is kept covered at all times.
4. Clean linen room shelves are wiped clean quarterly with a 1:10 bleach solution.
D. Soiled Linen Procedures:
1. It is a recognized fact that blood and body fluids may contain certain harmful
bacteria or viruses, and because soiled linen from healthcare facilities may have
been exposed to patient’s blood or body fluids, it must be regarded as a potential
source of infection. Patient confidentiality laws and the fact that patients are
admitted to healthcare facilities with undiagnosed infections mean our
employees usually handle soiled linen without knowledge of an individual’s
condition. It is important to understand that working with soiled linen that might
be contaminated does not have to be dangerous. If soiled linen is handled
properly, the risk of actual disease transmission is very small. In order to protect
themselves, all employees must apply the principles of standard precautions to
all soiled healthcare linens.
2. Clean linens are delivered to the CSU twice a week by a commercial laundry
company. At that time, they pick up the soiled linen that has been stored in a
secured area of the building. Bed linens are changed every three days and at
discharge. Clean bath linens are provided daily to each client.
E. Standard Precautions:
1. Standard Precautions are procedures utilized to minimize the risk of exposure to
bacteria and viruses in blood and body fluids through the use of personal
protective equipment, proper handling procedures and good personal hygiene.
By using these procedures, employee can handle soiled linen in a safe manner
regardless of the method of storage.
16. PEST CONTROL
16.1 Insects
A. Pest control services will be provided to all buildings in a manner and at times that will
not interfere with program operations nor endanger any person or property. A program
of prevention of insects or rodents is as important as a strong program of eradication
once an infestation has begun.
B. Insects need food, water, and a place to breed. Food can be human or animals for
bloodsucking insects, fresh or decomposing fruit or vegetables, or animal or human
excreta. Water is provided by drinking water, sewage, rainwater, and even moisture
27
producing appliances such as showers, dishwashing machines and washing machines.

Any place that remains relatively undisturbed and warm and is close to a supply of food
and water, make a good breeding places for insects. Control of insects then depends on
good sanitation. Careful use of insecticides also contributes to the control of insects. The
immunity of insects to common insecticides is a problem and specific insecticides may not
be reliable for prolonged periods of time. Good sanitation as applied to pest control shall
involve the following:
1. Window screens kept in good repair.
2. Garbage kept in containers with tight fitting lids.
3. Tin cans and other refuse stored in containers with tight fitting lids.
4. Garbage and waste containers kept clean and free from odors which might attract
pests.
5. Frequent disposal of wet and dry waste.
6. Frequent inspection of storage areas.
16.2 Rodents
A. Like insects, rodents are frequently attracted to similar environmental conditions.
Therefore, employees must be alert to signs of rodents such as droppings, freshly gnawed
surfaces, etc., which indicate the presence of rodents.
B. The functions of rodent control shall be assigned to licensed professional exterminators.
It shall be the responsibility of the Tri-County Safety Committee to monitor all pest control
programs. Each residential service unit will maintain a program of pest control that is
implemented on a regular basis by employee through contractual arrangements with a
local pest control company. Outpatient units will also follow the same procedures to
ensure an insect and rodent free environment for consumers and employees.
17. EDUCATION
A. Education and training of consumers will be conducted by nurses in the areas of general
health, nutrition, hand hygiene, oral health, safety, self-administration of medication, social
sexual awareness, prevention of illness and infection, communicable diseases, and other
health-related subjects as indicated by the individual units. Education is conducted individual
and in group settings. Individuals will receive education and training specific to the
individual’s assessed needs, ability, learning preferences, cooperation, and readiness to learn
as appropriate to the care and services provided by Tri-County.
B. Education regarding medication can include, but is not limited to:
1. Name and description of medication
2. Dosage, route of administration and duration of medication therapy
3. Intended use and expected actions of the medication therapy
4. Special directions and precautions for preparing, self-administering or using the
medication by the individual in the organization or at home
5. Action to be taken in the event of a wrong or missed dose
6. Significant side effects, interactions or therapeutic contraindications that may be
encountered and how to avoid and respond to such factors
7. Techniques for self-monitoring medication therapy
8. Proper storage and expiration of medications
9. Prescription refills
10. Drug-food interactions
28
11. Proper disposal of unused or expired medications
29

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Operating Procedures Medical Services

Tri-County Behavioral Healthcare Infection Control Program Manual

INFECTION CONTROL POLICIES AND PROCEDURES MANUAL

10.4 Thermometer Care......................................................................................................................... 14

INFECTION CONTROL POLICIES AND PROCEDURES MANUAL

4. AVAILABILITY AND DISTRIBUTION OF INFECTION CONTROL POLICIES AND PROCEDURES

5.4 Facility Infection Control Officer

A. Demonstrates knowledge of the definitions of significant infection, nosocomial and

6. EMPLOYEE HEALTH SCREENING AND PREVENTION ACTIVITIES

Common Cold Norovirus

7.3 Reportable Infections and Communicable Diseases

7. Expect follow-up phone contact from their department in days to follow.

8. NOSOCOMIAL AND COMMUNITY-ACQUIRED INFECTIONS

9. GENERAL METHODS OF PREVENTION AND CONTROL

f. Any contact with strong chemical solutions

e. Thoroughly rinse hands under running water.

8. Incidents of contaminated (used) needle stick injuries require the submission of

10.4 Thermometer Care

10.7 Re-use of Disposable Items

recognized occupational exposure issues that must be dealt with.

Contact: Nikalay Kanagin

11. SURVEILLANCE OF INFECTIONS

1. Illnesses That Will Require Transfer from Residential Facilities

that are taken, including the transfer of individual to a hospital or nursing

2. The Infection Control Committee may recommend innovative educational

13. MANAGEMENT OF EMPLOYEES OR INDIVIDUALS WITH HIV AND HBV

1. Individual cases shall be thoroughly reviewed by the physician in consultation

15. GENERAL HOUSEKEEPING

producing appliances such as showers, dishwashing machines and washing machines.

11. Proper disposal of unused or expired medications

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