5 Attachment D: LTC Gap Analysis

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment D: LTC Gap Analysis

AHRQ Safety Program for MRSA Prevention

Gap Analysis – Long Term Care Facilities

Instructions

Organization Name:
Date Completed:
Purpose:	To evaluate existing resources and processes and identify areas of improvement to facilitate interventions to reduce the incidence and prevalence of infections caused by methicillin-resistant Staphylococcus aureus (MRSA), the primary goal of participation in the AHRQ Safety Program for MRSA Prevention.
Outcome:	This gap analysis will be completed twice, once at the beginning and once at the end of participation in the AHRQ Safety Program. When completed at the start of the Safety Program, it will be used by the project team to understand needs of participating facilities and by participating facilities to prioritize areas for improvement and advocate for resources. When completed at the end of the Safety Program, both the project team and the participating facilities will use the gap analysis to assess progress in building infrastructure and capacity to sustainably reduce MRSA infections.
Instructions:	This gap analysis addresses infection control activities, specifically those related to MRSA prevention, in the participating facility and should be completed by the Project Lead for the participating facility in collaboration with the infection preventionist lead (if the Project Lead is not the infection preventionist). For each item, enter answers directly into the data portal in the indicated space. For some items, there will be a dropdown menu to allow you to select your answers.

Public reporting burden for the collection of information is estimated to average 1 hour per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857.

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.

Item Description	Response
INFECTION PREVENTION PROGRAM STRUCTURE AND RESOURCES
Facility Characteristics and Staffing
Please indicate what type of service(s) your facility provides for residents. (select all that apply)	Long-term general nursing care Long-term dementia care Skilled nursing care Short-term (subacute) rehabilitation Long-term psychiatric care Ventilator care Bariatric care Hospice or palliative care On-site Hemodialysis Center Comprehensive wound care Other: ___________
What is your facility’s capacity?	Fill in Answers: Total Beds: Average Census: Percentage of Short-Stay residents: Number of single rooms: Number of triple or quad rooms: Number of ventilator care beds:
Facility ownership	Select: Hospital owned Non-Hospital owned but part of larger health system Independent
Facility Payment Structure	Select: For Profit Not-for-Profit
Please describe your Staffing Ratios	Fill in answers: For Skilled/Short-stay/Vent units Registered nurse (RN)-to-Resident: Certified nursing assistant (CNA)-to-Resident: Respiratory therapist (RT)-to-Resident (if applicable): For Long-Term Units: RN-to-Resident: CNA-to-Resident:
Does your facility have a specific person with dedicated time who is responsible for coordinating the infection control program?	Yes / No
If yes, how many fulltime equivalents (FTEs) of this person are allocated to infection control activities?
If yes, has this person received specific training in infection control?	Yes / No
If yes, where was the training?
If yes, when was the training?	Within a year 1-5 years ago 6-10 years ago > 10 years ago
If yes to having a specific person who is responsible for the infection control program, does that person have access to an physician who can provide technical support regarding healthcare epidemiology and infection prevention issues?	No Yes, full-time Yes, part-time.
If yes to having an infectious diseases physician available to the infection prevention program, how often are they available to provide this support?	Not available Rarely Usually Always
Senior Leadership
To whom in senior leadership does the infection prevention program (or infection preventionist if there is no program) report? Please provide the leader’s position title/role or department, not a specific individual’s name.
How often does infection prevention meet with senior leadership?	Weekly Monthly Quarterly Annually Never Other: ___________
Does senior leadership actively promote/support infection prevention activities? (check all that apply)	No Yes: Participates as an Infection Control Committee member Yes: Provides adequate funding for infection prevention Yes: Provides funding for infection prevention member training Yes: Promotes infection prevention messages via newsletters, communications, screen savers, etc. Yes: Provides back up to the infection prevention program if employees do not follow policies and procedures Yes: Other: ____________
Is there a team or committee that reviews infection-control related activities?	Yes / No
If yes, please name members (I.e. charge nurse, administrator, Assistant Director of Nursing (ADON))
If yes, at what intervals does this team meet?	Daily Weekly Monthly Quarterly Annually
Data Analysis and Management
Is a data analyst available to assist with obtaining, managing, analyzing, and reporting infection prevention data?	No Yes, full-time Yes, part-time.
Is access to data analyst support adequate to meet program goals?	Yes / No
Select existing methods of storing infection data. (check all that apply)	Paper  Microsoft Excel or other spreadsheet  Microsoft Access or other relational database  Software that is part of the electronic health record system  Standalone infection prevention software   Other: (describe)
Which of the following Infection Prevention data is submitted to the Centers for Disease Control and Prevention (CDC)/National Healthcare Safety network (NHSN)? (check all that apply)	Multidrug resistant organism (MDRO) LabID Clostridioides difficile (C. difficile) Prevention process measures for hand hygiene Prevention process measures for enhanced barrier precautions Catheter-associated urinary tract infection (UTI) Annual facility survey Other: ___________ None
Microbiology
Is there access to a microbiology laboratory that performs microbiology tests?	Yes / No
Does the infection prevention team have access to microbiology results?	Yes / No
Is there a system for the lab to alert the infection control team about epidemiologically important microbiology results? (check all that apply)	Yes, cultures or tests positive for methicillin-resistant Staphylococcus aureus (MRSA) Yes, cultures or tests positive for other epidemiologically important results (e.g. carbapenem resistant Enterobacterales (CRE), extended-spectrum beta-lactamase (ESBL) producing organisms, C. difficile, etc.)  No, there is no system in place to alert about these organisms
Is there a system for the lab to alert units in the facility about epidemiologically important microbiology results? (check all that apply)	Yes, cultures or tests positive for MRSA  Yes, cultures or tests positive for other epidemiologically important results (e.g. carbapenem resistant Enterobacterales (CRE), extended-spectrum beta-lactamase (ESBL) producing organisms, C. difficile, etc.)  No, there is no system in place to alert about these organisms
Does your lab have the capacity, either in the facility or by sending the samples out to a reference lab, to process surveillance cultures?	Yes / No

Surveillance and Prevention Activities
Epidemiologically Significant Bacteria
General Questions
When a resident is transferred from your facility to a different facility (e.g., acute care hospital), is there a system or policy in place for your facility to provide information to the receiving facility about whether the resident is colonized or infected with MRSA, other multidrug-resistant organisms, and/or C. difficile? (check all that apply)	Yes, MRSA Yes, antimicrobial-resistant Gram negative organisms Yes, C. difficile Yes, other: No
When a resident is admitted or transferred to your facility, how often are you provided information about whether the resident is colonized or infected with MRSA, other multidrug-resistant organisms, and/or C. difficile.	Always Often Sometimes Almost Never Never
If your facility is notified that a resident admitted or transferred to your facility is colonized or infected with MRSA or other multidrug-resistant organisms, please indicated how that notification is generally made. (select all that apply)	A transfer form is completed and sent to the facility A verbal report is made conveying the information The information is noted in the medical record and flagged to draw attention to it Other:
Methicillin-resistant Staphylococcus aureus (MRSA)
Are residents who are colonized or infected with MRSA identified by the infection control team as soon as the relevant microbiology results are confirmed?	Yes / No
Are residents colonized or infected with MRSA placed on either contact isolation precautions or enhanced barrier precautions which require gowns and gloves for interactions with residents in their room?	Yes, all residents Yes, only residents with active MRSA infection Yes, only residents with higher risk of transmission (e.g., draining wounds, presence of an indwelling device) No
If yes, is there a system in place to monitor compliance with contact isolation precautions or enhanced barrier precautions?	Yes, the unit measures compliance Yes, infection prevention measures compliance No
If yes, how often is feedback about compliance provided to the unit? (check all that apply)	Weekly Monthly Quarterly Other: Feedback not provided
Is active surveillance for MRSA performed (e.g., obtaining nasal swabs for culture at set timepoints and/or repeating intervals following facility admission based on an established schedule)?	Yes, all residents Yes, select residents (specify): Yes, other: No
If yes, at what timepoints or with what frequency does active surveillance for MRSA occur? (check all that apply)	On admission Weekly Upon discharge Other:
If yes, is there a system in place to monitor compliance with obtaining MRSA surveillance swabs?	Yes / No
If yes, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
If yes, are rates of facility transmissions calculated (e.g., residents who have negative surveillance cultures on admission and develop MRSA colonization infection subsequently during the admission)?	Yes / No
If yes, are rates fed back to unit(s)?	Yes / No
If yes, indicate frequency:	Weekly Monthly Quarterly Other: Feedback not provided
Do most or all residents in the facility receive chlorhexidine (CHG) treatment (bathing)?	Yes / No
If yes to most or all residents receiving CHG bathing, indicate the usual frequency of CHG bathing.	Daily Every other day Weekly Other:
If yes to most or all residents receiving CHG bathing, estimate the proportion of patients who actually receive the intended treatment.	100% 75-99% 50-74% 25-49% <25%
If yes to most or all residents receiving CHG bathing,, is there a system in place to monitor compliance with CHG bathing?	Yes, the unit measures compliance  Yes, infection prevention measures compliance  Yes, both the unit and infection prevention measure compliance  No
If yes, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
If no to most or all residents receiving CHG bathing,, is CHG treatment (bathing) performed for residents with central lines or epidural catheters?	Yes / No
If yes to CHG bathing for patients with central lines or epidural catheters, indicate frequency:	Daily Every other day Weekly Other:
If yes to CHG bathing for patients with central lines or epidural catheters, estimate the proportion of residents with central lines or epidural catheters who actually receive the treatment.	100% 75-99% 50-74% 25-49% <25%
If yes to CHG bathing for patients with central lines or epidural catheters, is there a system in place to monitor compliance?	Yes, the unit measures compliance  Yes, infection prevention measures compliance  Yes, both the unit and infection prevention measure compliance  No
If yes to CHG bathing for patients with central lines or epidural catheters, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
Do most or all residents in the facility receive nasal decolonization ?	Yes, with Mupirocin Yes, with iodophor No
If yes indicate frequency: (check all that apply)	Twice daily for 5 days at the time of facility admission ☐ Every other week for 5 days Other:
If yes to most or all residents in the facility receiving nasal decolonization, is there a system in place to monitor compliance?	Yes, the unit measures compliance  Yes, infection prevention measures compliance  Yes, both the unit and infection prevention measure compliance  No
If yes to most or all residents in the facility receiving nasal decolonization, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
If no to most or all residents in the facility receiving nasal decolonization, is nasal decolonization performed for residents with MRSA infection or colonization?	Yes, with Mupirocin Yes, with iodophor No
If yes to nasal decolonization performed for residents with MRSA infection or colonization, indicate frequency: (check all that apply)	Twice daily for 5 days at the time of facility admission Every other week for 5 days Other:
If yes to nasal decolonization performed for residents with MRSA infection or colonization, is there a system in place to monitor compliance?	Yes, the unit measures compliance  Yes, infection prevention measures compliance  Yes, both the unit and infection prevention measure compliance  No
If yes, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
Carbapenem-resistant Enterobacterales (CRE) and Extended-Spectrum Beta-lactamase Producing (ESBL) Organisms
Are residents who are colonized or infected with CREs and/or ESBL-producing organisms identified by the infection control team at the time that the microbiology results are confirmed?	Yes / No
Are residents colonized or infected with CREs and/or ESBL-producing organisms placed on contact isolation precautions or enhanced barrier precautions which require gowns and gloves for interactions with residents in their room?	Yes, all residents Yes, only residents with active infection Yes, only residents with higher risk of transmission (e.g., draining wounds, diarrhea, presence of an indwelling device) No
Device Related HAIs
Central line-associated bloodstream infection (CLABSI)
Does your facility admit residents with central lines (including any of the following: dialysis catheters, accessed ports, tunneled catheters, temporary non-tunneled central lines, or peripherally inserted central catheters (PICCs)?)	Yes – Proceed to the following questions about central line-associated bloodstream infection (CLABSI) No – Skip the next section on CLABSI and proceed to the following questions about hand hygiene that begin on the bottom of page 9.
If your facility admits residents with central lines, is surveillance for CLABSI performed?	Yes / No
If yes to performing CLABSI surveillance, is it done via chart review, electronically by extracting data from the electronic health record or billing codes without chart review, or a combination of chart review and electronic data extraction?	Via chart review Electronically by extracting data from the electronic health record or billing codes without chart review Combination of both chart review and electronically by extracting data from the electronic health record or billing codes
If yes to performing CLABSI surveillance, are the CLABSI data fed back to units?	Yes / No
If yes to providing CLABSI data to the units, indicate frequency:	Weekly Monthly Quarterly Other: Feedback not provided
If your facility admits residents with central lines, does the facility focus on implementation of evidence-based practices for prevention of central line associated bloodstream infection (CLABSI) during central line maintenance?	Yes / No
If yes, indicate which of the following elements are included: (check all that apply)	Scrub the hub with friction before each use with an appropriate antiseptic Use sterile devices to access catheter Replace dressing that are wet, soiled or loose Routine sterile dressing changes Change administration sets with recommended frequency based on circumstances
If yes, is there a system in place to monitor compliance?	Yes, the unit measures compliance  Yes, infection prevention measures compliance  Yes, both the unit and infection prevention measure compliance  No
If yes, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
Hand Hygiene
Does the infection prevention program have a surveillance program in place to assess compliance with hand hygiene?	Yes / No
If yes, what are the elements of the program (check all that apply)?	Secret observations by unit staff Secret observations by individual not from the unit Observations followed by immediate feedback An electronic monitoring system Other (specify)
Are reports on compliance with hand hygiene developed and disseminated?	Yes / No
Is feedback regarding hand hygiene compliance provided to units?	Yes / No
If yes, indicate frequency:	Weekly Monthly Quarterly Other: Feedback not provided
Do staff at your facility receive training on performance of hand hygiene (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
Do staff at your facility receive competency validation on performance of hand hygiene (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
Personal Protective Equipment
Does the infection prevention program assess compliance with the use of contact isolation precautions or enhanced barrier precautions and the proper use of personal protective equipment?	Yes / No
If yes, what are the elements of the program? (check all that apply)	Observations by unit staff Observations by individual not from the unit Observations followed by immediate feedback Other (specify)
Are reports on compliance with use of personal protective equipment developed and disseminated?	Yes / No
Is feedback regarding use of personal protective equipment compliance provided to units?	Yes / No
If yes, indicate frequency:	Weekly Monthly Quarterly Other: Feedback not provided
Do staff at your facility receive training on use of personal protective equipment (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
Do staff at your facility receive competency validation on use of personal protective equipment (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
Does your facility have a system to ensure that personal protective equipment supplies (e.g., gloves, gowns, masks) readily available and restocked?	Yes / No
Environmental Cleaning
Does the infection prevention program have a surveillance program in place to assess compliance with cleaning of high-touch surfaces for both daily and discharge cleaning?	Yes / No
If yes, indicate which of the following are implemented: (check all that apply)	Observations of cleaning Application of fluorescent gel markers with follow up to see if markers are removed with cleaning Assessment of surface contamination with ATPase Other:
If yes, are reports on compliance with environmental cleaning developed and disseminated?	Yes / No
If yes, how often is feedback about compliance provided to the unit?	Weekly Monthly Quarterly Other: Feedback not provided
Do staff at your facility receive training on environmental cleaning (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
If yes, does it include the following (check all that apply):	Review of appropriate disinfectants for various situations Review of contact times of disinfectants Review of what order to clean in
Do staff at your facility receive competency validation on environmental cleaning (check all that apply)?	Yes, on hire Yes, annually Yes, other interval: No
Does your facility have a system to ensure that cleaning supplies are readily available and restocked?	Yes / No
Unit/Facility Quality Improvement Activities
How often does the infection preventionist visit the unit(s) routinely?	Daily Weekly Monthly Quarterly Never
Does the infection preventionist participate in the facility’s patient safety/quality improvement meetings?	Yes / No
Does the infection preventionist participate in rounds to assess compliance with the following at least quarterly:	Y/N Hand hygiene Y/N Compliance with the Centers for Disease Control and Prevention’s (CDC) contact isolation precautions or enhanced barrier precautions Y/N Other:
Is there a mechanism in place for systematic analysis and proactive learning from harmful events or events with potential of harm as raised by frontline staff (other than Morbidity and Mortality conferences or assessments/official Root Cause Analyses)	Yes / No

Supplemental Interventions Relevant to MRSA Prevention:

Antimicrobial Stewardship
Are there antibiotic stewardship (AS) processes in place to reduce use of unnecessary antibiotics?	Yes / No
If yes, indicate which of the following are implemented: (check all that apply)	Checklists/algorithms/guidelines regarding indications for sending cultures Checklists/algorithms/guidelines regarding indications for starting antibiotics Checklists/algorithms/guidelines regarding appropriate duration of antibiotics Daily time out by team to assess antibiotic use Post-prescription review and feedback Order sets for common infectious disease syndromes Activities to reduce the use of vancomycin Activities to reduce the use of fluoroquinolones

1 | Instructions