Section 1: Facility Demographics and Infection Prevention and

Infection Control Assessment and Response (ICAR) Tool for General Infection

Prevention and Control (IPC) Across Settings

Section 1: Facility Demographics and Infection Prevention and Control (IPC) Infrastructure

Long–Term Care

General Facility Demographics and IPC Infrastructure

Date of Assessment:

Facility Name:

State/Territory: County:

Zip Code: State/Territory-assigned Unique ID (if applicable):

Facility type (Complete the demographic form that

corresponds to the type of facility):

● Acute Care Hospital / Critical Access Hospital

● Long-term Care

● Outpatient/Ambulatory Care

● Other (specify):

NHSN Facility Organization ID (if applicable):

CMS Facility ID (if applicable):

Facility Respondent Name(s) and Job Title(s):

Rationale for assessment:

■ Requested by facility

■ Requested by accrediting agency/ licensing organization

■ Requested by state or local health department

■ HAI prevention focused:

■ CAUTI

■ CLABSI

■ SSI

■ CDI

■ Other (specify):

■ Prevention collaborative (specify partners):

■ Outbreak (specify):

■ Other (specify):

Obtain a list of products used for cleaning and disinfection of environmental surfaces and

non-critical patient/resident care equipment in the facility

EPA registration number(s) for products used in patient/resident rooms:

EPA registration number(s) for products used in common areas:

EPA registration number(s) for products used on non-critical patient/resident care equipment (e.g., blood glucose meters):

CS334433-M 12/14/2022

1. Does the facility have access to onsite IPC expertise?

● Yes

● No

● Unknown

● Not Assessed

If YES, specify:

Healthcare epidemiologist (number of full-time equivalents dedicated to IPC activities):

Infection preventionist (number of full-time equivalents dedicated to IPC activities):

Other (specify, including number of full-time equivalents dedicated to IPC activities):

Note: This is intended to identify individuals who work onsite at the facility or provide IP oversight at satellite locations (e.g., hospital IP provides IP

oversight to aﬃliated outpatient clinics) and what proportion of their time is dedicated to IPC activities. Example: The facility has two IPs. IP #1 spends

25% of their time on IPC activities and the rest of their time on direct patient care and IP #2 spends 75% of their time on IPC activities and the rest of the

time on direct patient care. This would be recorded as IP: 1 FTE dedicated to IPC activities. This breakdown could be further described in the notes.

2. Does the facility have access to offsite IPC expertise?

● Yes

● No

● Unknown

● Not Assessed

If YES, specify:

Healthcare epidemiologist (number of full-time equivalents dedicated to IPC activities at the facility):

Infection preventionist (number of full-time equivalents dedicated to IPC activities at the facility):

Other (specify, including number of full-time equivalents dedicated to IPC activities at the facility):

Note: This is intended to identify individuals who do not work primarily onsite at the facility but might provide IPC support on a contractual or part-time

basis. If a full-time equivalent cannot be determined, the level of support should be described in the notes.

3. Does the person(s) charged with directing the IPC program at the facility hold a nationally recognized credential in infection control

(e.g., a-IPC, CIC, LTC-CIP, BCIDP)

● Yes

● No

● Unknown

● Not Assessed

Lack of certification does not mean that an individual is not qualified to direct the IPC program.

Describe their qualification(s)

(e.g., other certifications, specialized training):

4. What additional duties are performed by

personnel within

the IPC program? (select all that apply)

■ Occupational Health

■ Education of personnel

■ Safety officer

■ Administrative (e.g., Director of Nursing)

■ None

■ Not assessed

■ Other (specify):

5. What does the director of the IPC program believe are the current strengths and weaknesses in the IPC program?

6. Does the IPC program have access to electronic medical records of patients/residents?

● Yes

● No

● Unknown

● Not Assessed

7. Does the IPC program utilize data mining/reporting software?

● Yes

● No

● Unknown

● Not Assessed

8. Does the IPC program perform an annual facility infection risk assessment that evaluates and prioritizes potential risks for infections,

contamination, and exposures and the program’s preparedness to eliminate or mitigate such risks

● Yes

● No

● Unknown

● Not Assessed

9. Are written infection control policies and procedures available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC),

regulations, or standards?

● Yes

● No

● Unknown

● Not Assessed

9a. How frequently are policies and procedures reviewed and updated? (select all that apply)

■ Annually

■ Every three years

■ As needed when new guidelines or evidence is published (e.g., via subscription with a publisher)

■ Unknown

■ Not assessed

■ Other (specify):

Note: Facilities should have a schedule to regularly review policies and procedures to ensure they are current. At a minimum, updates should be

made when new evidence-based guidance is published and if the scope of care delivered changes (e.g., new equipment is introduced or new procedures

are performed).

10. Does the IPC program provide infection prevention education to patients, family members, and other caregivers?

● Yes

● No

● Unknown

● Not Assessed

If YES:

10a. What topics are covered? (specify)

10b. How is this education provided (e.g., information included in the admission or discharge packet, videos, signage,

in-person training)? (specify)

11. Does the facility have an interdisciplinary infection control committee to address issues identified by the IPC program?

● Yes

● No

● Unknown

● Not Assessed

Note: Issues identiﬁed by the IPC program often impact multiple areas of the facility. An interdisciplinary committee, including facility leadership

(e.g., ownership, chief medical oﬃcer, director of nursing), is needed to allocate resources and successfully implement long-term solutions.

If YES, specify:

11a. Who is part of the infection control committee? (select all that apply)

■ Chief Medical Officer

■ Director of Nursing

■ Environmental Services

■ Unknown

■ Not Assessed

■ Other (specify):

11b. How often does the infection control committee meet?

■ Monthly

■ Quarterly

■ Unknown

■ Not Assessed

■ Other (specify):

Notes

Facility Demographics: Long–Term Care

1. Facility type (select all that apply):

■ Nursing home

■ Intermediate care facility

■ Assisted living facility

■ Inpatient Rehabilitation Facility

■ Other (specify):

2. Certification:

● Dual Medicare/Medicaid

● Medicare only

● Medicaid only

● State only

3. Ownership:

● For profit

● Not for profit, including church

● Government (not VA)

● Veterans Affairs

4. Affiliation:

● Independent, free-standing

● Independent, continuing care retirement community

● Multi-facility organization (chain)

● Hospital system, attached

● Hospital system, free-standing

5. Floor Plan/Layout: Number of Floors: Number of Units or Wings:

6. Total Number of Licensed Beds: Number of Pediatric Beds (age <21):

7. Current Census:

Unit Type

Number

of Rooms

Current

Census

Number of

single/private

rooms

Number of

doubles/

semi-privates

Number

of triples

Number

of quads

Subacute/Skilled

Long-term general nursing

Memory Care

Other (specify):

8. Does the facility have communal bathing areas?

● Residents have dedicated, private bathing areas

● Communal areas are used for showering

9. Does the facility provide onsite hemodialysis for residents?

● Yes

● No

9a. If yes, where is hemodialysis performed?

● Resident’s room

● Shared location in the facility (e.g., den)

● Other (specify):

10. What laboratory support is available? (select all that apply)

■ Onsite

■ Affiliated medical center, within same health system

■ Medical center, contracted locally

■ Commercial referral laboratory

■ Other (specify):

11. Which services are provided by contracted vendors? (select all that apply)

■ No services are contracted

■ Environmental Services/Housekeeping supervisors

■ Environmental services/Housekeeping frontline personnel

■ Linen/Laundry

■ Wound Care

■ Podiatry

■ Dental

■ Other (specify):

Ventilator Unit

12. Does the facility have ventilator-dependent residents or residents with tracheostomies NOT on a ventilator?

(If no, skip remainder of this section)

● Yes

● No

12a. Current census of residents with tracheostomies NOT on ventilators:

12b. Current census of ventilator-dependent residents:

12c. Do ventilator-dependent residents or those with tracheostomies participate in communal services/group activities

with residents who are not ventilator-dependent and do not have tracheostomies?

● Yes

● No

Note: Such mixing is residents is permissible; however, the facility will need to ensure they have policies and procedures (e.g., how and

where to safely perform suctioning, if indicated) and readily accessible supplies (e.g., hand hygiene and environmental cleaning supplies)

to minimize transmission risks.

12d. Is there a dedicated ventilator unit?

● Yes

● No

If NO:

12e. On which units are ventilator-dependent residents roomed? (specify units):

If YES:

12f. Are residents not on ventilators (e.g., patients with a trach or other device) ever roomed on the vent unit?

● Yes

● No

12g. Specify the types of rooms in the vent unit:

Room type Number per unit

Single rooms

Double rooms

Triple rooms

Quad rooms

■

Notes