Job Summary

Designation, Dedicated Time and Coverage

• The Incumbent is the SNF's Designated Infection Preventionist, as confirmed in writing by the Administrator and the Director of Nursing, and Works Full-Time (40 Hours Per Week) Onsite
• The Position is Dedicated to Infection Prevention and Control. The Incumbent May Not be Assigned Routine Direct-Care, Staffing, or Other Duties that Displace Required IPCP Work, and the IP's Hours are Not Counted Toward Minimum Direct-Care Staffing Hours
• A Written Coverage Plan Names a Qualified, Trained Backup for Planned Absences, and the Director of Nursing Reviews Completion of Required IPCP Activities at Least Monthly

Essential Duties and Responsibilities

• Performs Surveillance of Residents and staff when indicated, reported to have infections, or reported to Have Infections by collecting, analyzing, and Interpreting Documented Data
• Maintains the Infection Line List and Surveillance Report for Each Resident Who Has an Infection, and an Infection Control Log for Each Infection Occurring in the Facility Monthly
• Maintains a Tracking Log for MDRO Infections and Reviews Antibiotic Resistance Patterns, especially MDROs (MRSA, VRE, CRE, ESBL, and Others)
• Collaborates with Laboratory Staff on any Results Flagged with an MDRO
• Summarizes Data for Monthly, Quarterly, and Annual Reports
• Develops an Annual Surveillance Plan Based on the Population Served, Services Provided, and Analysis of Surveillance Data, and Evaluates and Modifies It, and the Infection Prevention and Control Policies and Procedures, as Needed and No Less than Annually
• Completes Required Reporting to the National Healthcare Safety Network (NHSN), CDPH, and Inyo County Public Health, with Accuracy and on Time

• Participates in the Antibiotic Stewardship Program and the Infection Control Committee to Ensure Safe and Appropriate Use of Antibiotics
• Reviews Every Antibiotic Order to confirm a Proper Indication for Use and Appropriateness for the Resident Based on Criteria Being Met, Including Whether Cultures were done before Treatment, the Physician Starting Therapy, and the Length of Therapy and any Changes During the Course of Treatment
• Reviews, Monitors, and Reports Antibiotic Usage Patterns, and Collects and Reviews the Types of Antibiotics Used in the Facility
• Coordinates and Consults with the Pharmacist or Pharmacy Consultant on Antibiotic Use, And Communicates with Physicians Regarding Appropriate Use of Antibiotic Medications
• Shares Feedback with Physicians on Individual Prescribing Patterns, Including Cultures Ordered and Antibiotics Prescribed

• Reviews the Assessment by the Facility Nurse for Appropriateness of Care for Infection Control and Adherence to Isolation Policies and Procedures, According to Evidence-Based Practices, Including Standard Precautions, Transmission-Based Precautions, and CDC Enhanced Barrier Precautions
• Completes the Infection Risk Assessment and Scale Upon Admission and When Changes in Condition Occur
• Conducts Resident Tuberculosis Screening During Admission Using A 2-Step Tuberculin Skin Test, with A Chest X-Ray When the Skin Test is Positive, Consistent with CDPH Guidance and District Policy
• Directs the Immunization Program for Influenza, RSV, COVID-19, and Pneumonia, Ensures Informed Consent or Declination is Completed, and Maintains a Current Immunization Log for All Residents

• Performs Daily Rounds in the Facility to Identify Infection-Control Issues and Problems, and Conducts In-Service Education when Needed to Correct Known Problems
• Performs Hand Hygiene Observations and Documents Findings for All Departments, Including Clinicians and Outside Contracted Providers
• Conducts and Reports Findings of Environmental Rounding for Infection Control Compliance in General Maintenance, Plumbing and Ventilation, Food Preparation and Storage, Laundry Collection and Cleaning, Infectious Waste Collection and Disposal, Housekeeping and Cleaning, Disinfection and Sanitation, and Equipment Cleaning

• Confirms, Investigates, and Reports Outbreaks, and Leads Response Efforts and Contact Tracing for Outbreaks Such as Influenza, COVID-19, and Gastrointestinal Illness
• Manages and Follows Up on Employee and Resident Exposures to Infectious Diseases, in Coordination with Employee Health
• Notifies the Medical Director, Director of Nursing, Administrator, and Public Health Authorities as Required, and Recommends Admission, Visitation, or Staffing Restrictions to The Medical Director and Administrator

• Ensures All Infection Prevention and Control Policies and Procedures are Complete, Up to Date, and Carried Out
• Maintains the Infection Prevention Quality-Control Plan and the Annual IPCP Risk Assessment

• Provides Infection Prevention Education at the Time of Hire, No Less than Annually, and when Training or Re-Education is Required or Needed
• Assists Employee Health with Education Programs for Staff on Proper Infection Control Practices
• Acts as Subject Matter Expert and Resource within the SNF to Residents, Families, Staff, Partners, Providers, Visitors, The Community, and Public Health Personnel on Infection Prevention and Control Measures, Including Identification of Infectious Disease Processes
• Creates a Process for Demonstrating Infection Prevention Competencies Following Each Training Activity

• Attends Quality Improvement Committee (monthly) and QAPI (quarterly) meetings and participates as a member of the QAPI Committee
• Collects and gathers data for committee review and reports monthly, quarterly, and annual findings of infection control data review and analysis to the QA Committee

• Complies With the SIHD Attendance Policy Requiring Regular, Reliable, and Punctual Attendance
• Complies With HIPAA and District Privacy and Security Policies, and Handles Confidential Information and Protected Health Information as Authorized and Necessary for Assigned Duties
• Adheres to All District Policies and Procedures, Completes Work Promptly in Compliance with State and Federal Regulations, Accepts New Assignments, and Initiates New Projects as Indicated
• Demonstrates Flexibility and Willingness to Adapt to Workday Expectations as the Need Arises, and Performs Other Duties as Assigned

Regulatory Requirements for the 33-Bed SNF

Knowledge, Skills and Abilities

• CDPH Title 22, CDC, NHSN, OSHA, and CMS Infection Control Program Regulations
• NHSN Reporting Guidelines and Timelines, the NHSN Reporting Portal, and Mandatory SNF Reporting Requirements for HAIs
• Surveillance Methods and Standardized Infection Definitions, Antibiotic Stewardship, and MDRO Management
• Familiarity with CDPH Survey Processes and Guidelines, and Inyo County Public Health Resources and Reporting Processes
• Outbreak Investigation, Contact Tracing, and Quality-Improvement Methods

• Communicate Clearly in Both Oral and Written Forms Using the English Language; Bilingual English/Spanish Preferred
• Respond to Common Inquiries or Complaints from Residents, Patients, Physicians, Peers, Regulatory Agencies, or Members of the Business Community
• Work Independently, Set Priorities, and Manage Multiple Deadlines
• Work with Confidential Information and Handle Protected Health Information Consistent with HIPAA
• Collect, Analyze, and Present Data and Use it to Drive Improvement
• Tolerate Wearing Required Personal Protective Equipment (PPE) for Prolonged Periods

Minimum Qualifications

• Current California Nursing License, Maintained in Good Standing
• College Degree in Nursing, Public Health, Epidemiology, Clinical Laboratory Science, Medical Technology, or a Related Field

• Valid CPR and BLS Certification, Kept Current During Employment
• Successful Completion of an Infection Prevention and Control Training Program Meeting CDPH AFL 20-84 (Initial Training of at Least 14 Hours) Within Three (3) Months of Hire
• Successful Completion of the CDC Antibiotic Stewardship Training Program Within Six (6) Months of Hire
• At Least 10 Hours of Continuing Education in Infection Prevention and Control Each Year
• These are Employment Expectations Unless the District Formally Approves an Exception Based on Documented Circumstances

• Satisfactory Completion of the Conditions of Employment Under Hr-032, Including Criminal Background Clearance as Required by California Law for Long-Term-Care Personnel, Drug Test, Tuberculosis and Other Required Health Clearance, Physical Exam, and Satisfactory References
• Ability to Meet Immunization and Health-Clearance Requirements Applicable to Long-Term-Care Personnel

Preferred Qualifications

• Two or More Years of Experience as an Infection Preventionist
• Two or More Years of Experience as an LVN Or RN
• Knowledge of and Previous Experience with Infection Control Surveillance
• Board Certification in Infection Control, Such as CIC or LTC-CIC Through CBIC, and Membership in a Local APIC Chapter
• Bilingual English/Spanish Ability
• Experience With NHSN, QAPI, Survey Readiness, And Outbreak Response in a Skilled Nursing or Long-Term Care Setting

Performance Measures

1. Surveillance and Reporting

2. Antibiotic Stewardship

3. Precautions, Screening and Immunization

4. Rounds, Audits and Environmental Compliance

5. Outbreak and Exposure Management

6. Education, Policies and Competency

• The Director of Nursing reviews a monthly scorecard with the Incumbent, and Chief Operating Officer and QAPI Committee Review It Quarterly
• Any Miss on A Measure Tied to A Regulatory Timeframe Triggers a Documented Root-Cause Review within 5 Business Days and a Corrective Plan
• Two Consecutive Months Below Target on any Measure, or any Miss that Results in A Survey Citation, Triggers A Formal Performance Review with the Director of Nursing and Human Resources
• A Baseline Period of Up To 90 Days After Hire or Adoption of these Measures May Be Used to Calibrate Rate-Based and Non-Regulatory Targets
• Results Affected by Factors Outside the Incumbent's Control, Such as Staffing Shortages, Laboratory Delays, or Outbreaks, are Documented and Considered
• Metrics Inform, and Do Not by Themselves Determine, the Overall Performance Evaluation, which Also Considers the Duties, Behavioral Expectations, and Compliance Requirements in this Job Description

Working Conditions and Physical Requirements

• Extended Periods of Sitting, Standing, and Walking
• Performing Rounds or Environmental Checks May Require Bending, Twisting, Reaching, and Squatting
• Periods of Lifting and Carrying Up To 25 Pounds When Transporting Equipment, Manuals, or Testing Supplies
• Clear and Audible Speaking Voice and the Ability to Hear Normal Speech Levels to Observe Resident Environments, Monitor Data Reports, And Communicate Clearly in Person and on the Phone
• Dexterity to Operate Computers, Analyze Laboratory Data, and Handle Specialized Medical or Testing Instruments
• Regular Exposure to Communicable Diseases and Hazardous Substances
• Must Be Able to Tolerate Wearing Required PPE For Prolonged Periods

Role Authority and Escalation