Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19

Please note — SARS-CoV-2 guideline updates may affect the usability of the current Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19, which was lasted updated in June 2022. We encourage partners to begin transitioning to use of the ICAR Tool for General IPC Across Settings (https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html).

Infection Control Assessment and Response (ICAR) tools are used to systematically assess a healthcare facility’s infection prevention and control (IPC) practices and guide quality improvement activities (e.g., by addressing identified gaps).

This tool is an update to the previous ICAR tool for nursing homes preparing for COVID-19. Notable changes as of June 13, 2022 include:

Additions to reflect updated guidance such as work restrictions for healthcare personnel with SARS-CoV-2 infection and exposures, and updated language regarding vaccination.

Similar to previous updates, facilitators may decide whether to use the tool in its entirety or select among the pool of questions that best fit their jurisdictional needs and priorities as part of quality improvement efforts.

In-person versus remote ICAR

The decision to conduct an assessment in-person or remotely via a TeleICAR depends upon several factors, such as available public health resources, the location and remoteness of the facility, and the presence of an active outbreak. For facilities with recent cases of SARS-CoV-2 infection in healthcare personnel or residents, an in-person assessment is preferred; however, jurisdictions must individually determine how to best provide assistance in the timeliest manner.

In-person ICARs:

are preferred whenever possible, especially for facilities experiencing an outbreak
are not prone to the same technical limitations (e.g., video function failure) that may occur during a remote ICAR
typically allow the facilitator performing the ICAR to visualize more of the facility’s IPC practices

Remote TeleICAR assessments:

allow for a larger number of facilities to be reached in a shorter amount of time
allow for limiting potential exposures to SARS-CoV-2
are unlikely to identify as many gaps in practices as in-persons visits, even with the addition of the video component

Steps to an ICAR

blue process flow arrows illustrating the Steps of an ICAR

Contact the facility to schedule the ICAR
Conduct the ICAR
Provide feedback to the facility
Follow-up on ICAR feedback implementation

Whether conducting an ICAR in person or remotely (i.e., TeleICAR), the steps to the ICAR process are similar. In most instances, it involves scheduling the ICAR, conducting the ICAR with the preconstructed tool to guide the assessment, providing both verbal and written feedback to the facility, and then following-up on how the facility is implementing the suggested improvements. More information on these steps can be found in the Frequently Asked Questions at the bottom of this page.

How to use this ICAR tool

This tool is intended to help assess IPC practices for nursing homes without an active outbreak of COVID-19. However, public health jurisdictions may choose to modify this tool to fit their needs beyond this defined scope. For example, jurisdictions may choose to modify the tool to assess facilities experiencing an outbreak. While many of the concepts covered in this tool should be reviewed regardless of outbreak status (e.g., PPE use, hand hygiene, environmental cleaning), some areas may require more in-depth review such as current outbreak epidemiology (e.g., affected units, number of exposed HCP and residents), resident cohorting strategies, facility management of symptomatic or exposed residents, testing strategies, and mitigating staffing shortages. In addition, the video or in-person tour should dedicate more time to observing IPC practices in the designated COVID-19 area.

The tool is available in both a facilitator guide and a non-facilitator guide format.

The facilitator guide format contains both the question and answer choices as well as the recommended IPC practice(s) based upon current CDC guidance. By having ready access to the recommend practice(s), the facilitator may provide immediate verbal feedback and recommendations to the facility during the assessment.
The non-facilitator guide format only contains the question and answer choices.
Section 1 of the ICAR collects facility demographics and critical infrastructure information and is intended for completion by the facility prior to the ICAR (provided as separate PDF to send to facility, Section 1: Demographics and Critical Infrastructure [373 KB, 3 pages]). These questions are often ones that require the facility to look up or consult with certain staff members and thus pre-collection often saves times during the actual assessment. The ICAR facilitator should decide if any of the responses need to be verbally reviewed or require further explanation at the beginning of the assessment. If no further clarification is needed, then the facilitator should start on the next section and refer to this section as needed. Section 1 of the facilitator guide provides the rationale behind the questions, and how the answers may be utilized during the rest of assessment.

Most ICARs, whether remote or in-person, begin with a discussion of current IPC policies and practices. Following this discussion, a facility tour can assess how the facility is implementing many of these discussed strategies. If the ICAR can only be conducted remotely, the assessment facilitator should include a video tour whenever possible.

The TeleICAR team within the Division of Healthcare Quality Promotion can provide training to public health jurisdictions on the use of the tool, including TeleICAR demonstrations with facilities. A Frequently Asked Questions document regarding TeleICAR remote assistance is available at the bottom of this page. For more information contact, teleicar@cdc.gov.

Infection Prevention and Control Assessment and Response Tools (ICAR)

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Frequently Asked Questions about Remote TeleICAR Assessments

At a minimum the facility’s administrator(s) and infection preventionist should be present. The environmental services/housekeeping supervisor should also be present for at least the portion of the assessment involving this domain. Many times, additional healthcare personnel (HCP) such as directors of nursing and assistant directors of nursing will join. During a video tour, assessing frontline HCP knowledge and observing their practices may increase the quality of the assessment and result in more meaningful recommendations for the facility.

The TeleICAR facilitator should be knowledgeable on relevant and current COVID-19 state and federal infection prevention guidance. The facilitator guide tool helps highlight some of relevant CDC guidance to aid in this process. In addition, it is helpful for facilitators to have some knowledge of infection prevention and control in healthcare systems; however, with enough training from more experienced facilitators, even those with limited past background can conduct a TeleICAR.

Ultimately each public health jurisdiction should decide upon a process that works for them. Some factors to consider:

Who is responsible for facility outreach? Will this responsibility be shared by all TeleICAR facilitators or just one?
How will you introduce the TeleICAR process to facilities? By a phone call? Via email? Having a script that TeleICAR facilitators can use to describe the process and expectations helps ensure a standardized process.
Will you be conducting a video tour? How do you ensure the TeleICAR facilitators and the facility have access to and can successfully use the selected video conferencing platform?
How will you document the scheduling process such as date(s) of facility contact, date of TeleICAR completion, etc.?

The CDC TeleICAR team can provide more guidance and help with navigating the scheduling process and can be reach at: teleicar@cdc.gov.

This depends upon several factors such as the facility’s baseline infection prevention and control (IPC) practices, the number and type of questions that arise as part of the TeleICAR, and the experience of the TeleICAR facilitator. Most remote TeleICAR assessments using this tool with a video tour take 1.5-2 hours. Despite the length, most facilities are willing to dedicate this time if this expectation is set during the ICAR scheduling process. Additionally, a video tour can be scheduled at a different time if the facility cannot accommodate all sections in one session.

The purpose of any ICAR whether conducted in-person or remotely is to help facilities improve their current IPC practices. Thus the ICAR is just the first step in this improvement process as facilities must still implement the provided recommendations. The amount and type of follow-up support a facility will need during the implementation process will vary. Some facilities with few IPC gaps may require little further follow-up. However, facilities with many IPC gaps will require more follow-up support which may range from remote trainings and repeat assessments to in-person visits. If only a remote TeleICAR was conducted, consideration of an in-person visit to a facility is needed if identified IPC gaps are urgent or serious in nature.

A RedCap database has been created for public health jurisdictions to enter the responses collected by using the ICAR tool. To inquire about access to this database tool, please email: teleicar@cdc.gov.

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