ASF Standards · Long-Term Care · Standard 4
Standard 4 — Clinical & Medical Care
Criteria in this standard
4.1 — Monthly Pharmacist Medication Review Actually Catches Unnecessary Drugs
4.2 — Psychotropic Medications Require a Documented, Specific Diagnosis, Not General Behavior Management
4.3 — Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications
4.4 — PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically
4.5 — Infection Control Follows a Defined, Facility-Specific Program
4.2 — Psychotropic Medications Require a Documented, Specific Diagnosis, Not General Behavior Management
4.3 — Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications
4.4 — PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically
4.5 — Infection Control Follows a Defined, Facility-Specific Program
4.1
Monthly Pharmacist Medication Review Actually Catches Unnecessary Drugs
Non-Negotiable
A licensed pharmacist reviews every resident's complete drug regimen at least monthly, with any irregularity — excessive dose, excessive duration, inadequate monitoring, inadequate indication — specifically reported to the attending physician and acted upon, not a review that occurs on schedule but produces no real consequence.
In plain terms: A pharmacist reviews every resident's full medication list at least monthly and actually finds and reports unnecessary, excessive, or dangerous drugs — with evidence that the findings lead to changes.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
The average care home resident takes nine medications. Many are unnecessary — started years ago for a problem that resolved, continued by habit, prescribed by different doctors who never spoke. Polypharmacy causes falls, confusion, kidney damage, and death. A monthly pharmacist review — every drug, every dose, every interaction, every duplicate, every drug without a current indication — finds these. But finding is not enough: the pharmacist's recommendations must go to the physician, and the physician must respond. A review that produces a report nobody acts on is a review without effect.
What good looks like
- Every resident receives a genuine, complete monthly pharmacist review.
- Irregularities are specifically reported to the attending physician, medical director, and director of nursing.
- Real evidence shows reported irregularities are genuinely acted upon.
Common failure modes
- Pharmacist review is inconsistent, partial, or lapses for some residents.
- Irregularities are identified but not specifically reported to the required individuals.
- Reports produce no documented action or resolution.
Worked example
In practice
A 70-bed care home with a contracted pharmacist who reviewed records quarterly.
BeforeThe pharmacist reviewed medication administration records quarterly and wrote a report. The physician rarely read it. The Coordinator reviewed 30 residents' medications with the pharmacist: average 10.5 drugs; 40% had at least one drug with no current indication; 6 had two anticholinergics; 3 had a duplicate.
ActionThe pharmacist review became monthly, structured with a validated tool (STOPP/START or equivalent), with each finding categorised by urgency. Recommendations go to the physician with a required response (accepted, declined with reason) within 14 days. Declined recommendations are reviewed at the medical advisory meeting. The home tracks the number of recommendations, acceptance rate, and average drugs per resident.
AfterThe Monitor reviewed six months of pharmacist reviews with physician responses (acceptance rate 78%), and the trend in average drugs per resident (10.5 → 8.1). Verified.
If you are starting from zero — do this first
- Count the drugs for ten residents. Average over eight is a flag.
- Move pharmacist review to monthly with a validated tool.
- Require a physician response to every recommendation within 14 days.
- Track drugs per resident monthly.
The most common mistake: A pharmacist review that produces a report nobody acts on.
Self-assessment questions
1. Does a licensed pharmacist review every resident's complete drug regimen at least monthly? — A genuine, complete review, not a partial check or one that lapses under pressure.
Evidence: Monthly pharmacist review record
Evidence: Monthly pharmacist review record
2. Are identified irregularities specifically reported to the attending physician, medical director, and director of nursing? — Specific, documented reporting to the right people, not an informal or incomplete escalation.
Evidence: Irregularity reporting record
Evidence: Irregularity reporting record
3. Is there real evidence that reported irregularities are actually acted upon, not just noted and filed? — Genuine action resulting from the report, not a report that produces no real consequence.
Evidence: Irregularity resolution record
Evidence: Irregularity resolution record
Common reasons for a PARTIAL answer
- Review happens monthly but doesn't consistently cover every category of potential irregularity. — A review that misses a category of concern provides only partial protection.
- Reporting happens but response time from the attending physician is inconsistent. — A report without a prompt, genuine response doesn't provide the real protection this process is meant to ensure.
- Irregularities are resolved for individual cases but patterns across residents aren't reviewed collectively.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current pharmacist review practice for consistency and completeness. |
| Week 2 | Establish clear reporting pathways to the attending physician, medical director, and director of nursing. |
| Week 3 | Build a tracking process confirming irregularities lead to genuine action. |
| Ongoing | Review irregularity patterns across residents for systemic issues. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Monthly review record check | Reviews pharmacist review records for consistent, complete monthly coverage of every resident. |
| DOCUMENT | Irregularity reporting review | Reviews evidence that identified irregularities are specifically reported to the correct individuals. |
| ASK | Resolution outcome interview | Asks staff for a real example of an irregularity that was identified and what actually happened as a result. |
Supervisor tips
- Ask for a real, recent example of an irregularity and trace it through to its actual resolution. — A real, traced example reveals whether the process genuinely functions, not just exists on paper.
- Ask the attending physician how quickly they typically respond to a pharmacist-identified irregularity. — A specific, confident answer reveals genuine, prompt engagement with the process.
Evidence base
[16] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require regular licensed pharmacist review of each resident's complete drug regimen, with identified irregularities reported to the attending physician, medical director, and director of nursing, and acted upon.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
4.2
Psychotropic Medications Require a Documented, Specific Diagnosis, Not General Behavior Management
Non-Negotiable
A resident is never started on a psychotropic medication without a specific, diagnosed, clinically documented condition justifying its use — never as a general response to behavior, agitation, or the convenience of managing a resident who is difficult to care for.
In plain terms: No resident is started on an antipsychotic, sedative, or other psychotropic without a specific diagnosed condition that justifies it — 'agitation' or 'behaviour' is not a diagnosis.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Antipsychotics in dementia increase death by about 60%. They cause strokes, falls, and pneumonia. They do not treat dementia; they sedate the person so staff are less troubled. For decades they were prescribed for 'agitation' — a description of behaviour, not a diagnosis. The standard is now clear: a psychotropic requires a documented psychiatric diagnosis for which the drug is indicated (schizophrenia, bipolar disorder, major depression, specified psychosis), the diagnosis must be made by an appropriate clinician, and the prescription must be reviewed. 'Behaviour management' is not an indication; it is a confession that the resident's needs are not being met.
What good looks like
- Every psychotropic medication is tied to a specific, documented diagnosis.
- Non-pharmacological approaches are genuinely tried first.
- Staff can describe the specific condition behind a resident's medication.
Common failure modes
- Psychotropic medication is used as a general response to behavior or agitation.
- No genuine attempt at non-pharmacological approaches precedes medication.
- Staff describe the medication's purpose only in general behavioral terms.
Worked example
In practice
A 60-bed dementia care unit where 45% of residents were on an antipsychotic.
BeforeAntipsychotics were started when residents were 'agitated' or 'resistive.' The indication in the record was 'behaviour' or 'dementia with agitation.' No psychiatric diagnosis. Physicians prescribed on staff request. The unit's antipsychotic rate was more than double the national benchmark.
ActionA psychotropic prescribing policy was written: no new psychotropic without a specific diagnosis documented by a physician or psychiatrist, with the target symptoms specified; a behavioural assessment (5.1) required first; pharmacist review of every existing psychotropic for indication; a plan to taper any without a valid diagnosis (4.3). The medical director reviewed every antipsychotic prescription over three months.
AfterThe Monitor reviewed 30 psychotropic prescriptions: all with a documented specific diagnosis or a taper plan. Antipsychotic rate down from 45% to 18% in nine months. Verified.
If you are starting from zero — do this first
- List every resident on an antipsychotic. For each, what is the diagnosis in the record?
- If the indication is 'agitation,' 'behaviour,' or 'dementia' alone, that is not a diagnosis.
- Write the policy: specific diagnosis required, behavioural assessment first.
- Review every existing prescription.
The most common mistake: Accepting 'dementia with agitation' as a diagnosis — it is a description of a distressed person whose needs are unmet.
Self-assessment questions
1. Is every psychotropic medication tied to a specific, diagnosed condition documented in the clinical record? — A specific, documented diagnosis, not a general behavioral rationale.
Evidence: Psychotropic medication diagnosis documentation
Evidence: Psychotropic medication diagnosis documentation
2. Are non-pharmacological, behavioral approaches genuinely tried first, before psychotropic medication is started? — Real, attempted alternatives, not psychotropic medication as the default first response.
Evidence: Behavioral intervention documentation
Evidence: Behavioral intervention documentation
3. Can staff describe the specific diagnosed condition behind a particular resident's psychotropic medication? — Specific, genuine knowledge, not a general sense that the medication helps with behavior.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- New psychotropic orders have specific documented diagnoses but older, long-standing orders lack the same clarity. — Every psychotropic medication deserves the same documented justification, regardless of when it was originally started.
- Behavioral approaches are documented as considered but the actual attempt isn't clearly described. — Considering an alternative isn't the same as genuinely attempting it before resorting to medication.
- Diagnosis documentation exists but isn't consistently reviewed for continued accuracy over time.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current psychotropic medication orders for specific, documented diagnostic justification. |
| Week 2 | Establish or strengthen non-pharmacological intervention practice and documentation. |
| Week 3 | Train staff on the specific diagnosed conditions behind each resident's psychotropic medications. |
| Ongoing | Review long-standing psychotropic orders for continued diagnostic accuracy. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Diagnosis documentation review | Reviews psychotropic medication orders for a specific, documented diagnosed condition, not general behavior rationale. |
| DOCUMENT | Behavioral intervention review | Reviews documentation of non-pharmacological approaches genuinely attempted before medication initiation. |
| ASK | Staff knowledge interview | Asks staff to describe the specific diagnosed condition behind a particular resident's psychotropic medication. |
Supervisor tips
- Ask about a specific, long-standing psychotropic order, not only recently started ones. — This is where documentation most commonly grows stale or unclear over time.
- Ask a front-line staff member, not only a nurse, what the medication is specifically for. — This reveals whether specific understanding genuinely extends through the care team.
Evidence base
[17] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, prohibit psychotropic drug use unless necessary to treat a specific condition that is diagnosed and documented in the resident's clinical record.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
4.3
Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications
Non-Negotiable
Residents on psychotropic medication receive genuine, documented gradual dose reduction attempts combined with behavioral interventions, unless a specific clinical reason makes this genuinely contraindicated — not medication continued indefinitely without any real attempt to reduce or discontinue it.
In plain terms: For residents on psychotropics, the home genuinely tries to reduce the dose — gradually, with behavioural support, documented — unless a doctor records a specific reason why not.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Once started, psychotropics are rarely stopped. The resident who was sedated during a crisis two years ago is still sedated. Gradual dose reduction — reducing by a step, watching, reducing again, with behavioural interventions in place — is how residents are freed from drugs they no longer need. It must be genuine: a documented attempt, not a note saying 'GDR considered.' It must be gradual: abrupt withdrawal causes rebound. It must be supported: behavioural approaches replace the drug. And if the physician judges a reduction unsafe, the reason must be specific and documented — 'clinically contraindicated' without explanation is not a reason.
What good looks like
- Every resident on psychotropic medication has a genuine, documented reduction attempt.
- Contraindication, where determined, is backed by specific documented clinical reasoning.
- Behavioral interventions are genuinely combined with reduction attempts.
Common failure modes
- Medication continues indefinitely with no documented reduction attempt.
- Contraindication is assumed or undocumented, without real clinical basis.
- Dose reduction, if attempted, happens without any behavioral intervention alongside it.
Worked example
In practice
A 50-bed care home where psychotropics, once started, were continued indefinitely.
BeforeNo dose reduction had been attempted for any resident in living memory. The record said 'GDR not indicated' for most, with no reason. A resident had been on haloperidol for four years following a single episode of agitation after a hospital admission.
ActionA GDR protocol was implemented: every resident on a psychotropic has a reduction attempt within three months of the review, then at least twice in the first year, unless the physician documents a specific clinical reason; reductions are stepwise (typically 25% per 2–4 weeks) with behavioural support and monitoring; outcomes are recorded. The pharmacist tracks all residents' GDR status. The haloperidol patient was tapered off over six weeks without incident.
AfterThe Monitor reviewed 25 psychotropic records: all had documented GDR attempts or specific physician reasons; 14 residents had been successfully reduced or discontinued. Verified.
If you are starting from zero — do this first
- List every resident on a psychotropic and the start date.
- For each, when was a dose reduction last attempted?
- Start with the resident who has been on the drug longest with the least clear indication.
- Reduce by a step, watch for four weeks, document.
The most common mistake: Writing 'GDR not indicated' without a reason — that is a decision not to try.
Self-assessment questions
1. Does every resident on psychotropic medication have a genuine, documented gradual dose reduction attempt? — A real, documented attempt, not medication continued indefinitely by default.
Evidence: Gradual dose reduction documentation
Evidence: Gradual dose reduction documentation
2. Where gradual dose reduction is considered clinically contraindicated, is the specific clinical reason documented? — A specific, documented clinical justification, not contraindication assumed without real basis.
Evidence: Contraindication documentation
Evidence: Contraindication documentation
3. Are behavioral interventions combined with dose reduction attempts, not medication reduction alone? — Genuine combined approach, not dose reduction attempted in isolation.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- Reduction attempts happen for some residents but not consistently across the full population on psychotropic medication. — Every resident on this medication deserves the same genuine, periodic reconsideration.
- Contraindication documentation exists but doesn't specifically address why this particular resident's situation warrants it. — A generic contraindication rationale doesn't reflect the genuine, individual clinical judgement this requires.
- Reduction is attempted but not systematically tracked to know whether it was ultimately successful.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current psychotropic medication population for documented reduction attempts. |
| Week 2 | Establish a systematic process for periodic dose reduction consideration. |
| Week 3 | Build genuine behavioral intervention practice alongside reduction attempts. |
| Ongoing | Track reduction attempt outcomes to inform future practice. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Dose reduction attempt review | Reviews documentation of genuine, attempted gradual dose reduction for residents on psychotropic medication. |
| DOCUMENT | Contraindication justification review | Reviews the specific, documented clinical reasoning behind any contraindication determination. |
| ASK | Combined approach interview | Asks staff whether behavioral interventions are genuinely combined with dose reduction attempts. |
Supervisor tips
- Ask for a specific resident's dose reduction history over the past year. — A real, traceable history reveals whether reduction is genuinely attempted, not just theoretically required.
- Ask what behavioral intervention accompanied a specific reduction attempt. — A specific, real answer reveals genuine combined practice, not medication-only reduction.
Evidence base
[18] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require residents using psychotropic drugs to receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in a genuine effort to discontinue these drugs.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
4.4
PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically
Non-Negotiable
As-needed psychotropic medication orders are limited to 14 days, with antipsychotic PRN orders specifically requiring a physician re-evaluation before any renewal — not extended or renewed automatically as a matter of routine.
In plain terms: As-needed psychotropic orders expire after 14 days; PRN antipsychotics need a doctor's face-to-face review to continue — they are never auto-renewed.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
A PRN sedative order written 'for agitation' with no expiry becomes a standing permission to sedate at staff discretion, indefinitely. The resident is given lorazepam whenever a shift is short-staffed. The 14-day limit forces a review: is the drug still needed? Is it being used appropriately? What is the pattern? For antipsychotics, the review must be by a physician who has seen the resident — not a phone renewal. The rule is deliberately inconvenient; convenience is how PRN psychotropics become chemical restraint.
What good looks like
- PRN psychotropic orders are genuinely limited to 14 days.
- Antipsychotic PRN renewal requires a real, documented physician re-evaluation.
- Any extension beyond 14 days carries specific, documented clinical rationale.
Common failure modes
- PRN orders are routinely extended or renewed without genuine time limits.
- Antipsychotic renewal happens without real re-evaluation.
- Extensions lack specific clinical rationale.
Worked example
In practice
A 60-bed care home where PRN lorazepam orders had no expiry.
BeforePRN psychotropic orders were written once and used for months or years. The Coordinator found a resident whose PRN lorazepam order was three years old and had been used 140 times in the previous six months, almost always on night shift. No review had occurred.
ActionThe medication system was configured to expire all PRN psychotropic orders at 14 days. Renewal requires a physician review; for antipsychotics, a documented face-to-face assessment. The nurse manager reviews PRN administration patterns weekly — frequency, shift, staff member — and any pattern suggesting convenience use is escalated. Behavioural alternatives are documented before each PRN dose.
AfterThe Monitor reviewed the PRN order register (all current orders under 14 days or renewed with documented review), the weekly administration pattern reports, and PRN psychotropic use down 70%. Verified.
If you are starting from zero — do this first
- List every PRN psychotropic order and its date. Any over 14 days is out of compliance.
- Configure the system to expire PRN psychotropics at 14 days.
- Require face-to-face physician review for PRN antipsychotic renewal.
- Review PRN use patterns weekly by shift.
The most common mistake: PRN orders that renew automatically — an open-ended PRN sedative is a licence for chemical restraint.
Self-assessment questions
1. Are all PRN psychotropic orders genuinely limited to 14 days, not extended automatically? — A genuine, enforced 14-day limit, not a routine extension.
Evidence: PRN order duration record
Evidence: PRN order duration record
2. Does any PRN antipsychotic renewal require a genuine physician re-evaluation, not automatic continuation? — A real, documented re-evaluation specifically for antipsychotics, not a rubber-stamp renewal.
Evidence: Antipsychotic renewal re-evaluation documentation
Evidence: Antipsychotic renewal re-evaluation documentation
3. Where a PRN order is extended beyond 14 days for a non-antipsychotic, is the physician's rationale specifically documented? — A specific, documented clinical rationale, not an extension without real justification.
Evidence: Extension rationale documentation
Evidence: Extension rationale documentation
Common reasons for a PARTIAL answer
- The 14-day limit is tracked for most orders but occasionally lapses during staff transitions. — Consistent tracking regardless of staffing changes is what makes this limit genuinely reliable.
- Re-evaluation happens for antipsychotic renewals but isn't always documented with specific clinical detail. — Undocumented re-evaluation is difficult to distinguish from renewal without genuine reconsideration.
- Extension rationale is documented but sometimes generic rather than specific to the individual resident's situation.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current PRN psychotropic order tracking for genuine 14-day limit enforcement. |
| Week 2 | Establish a specific re-evaluation process required before any antipsychotic PRN renewal. |
| Week 3 | Train prescribing staff on documentation requirements for any extension beyond 14 days. |
| Ongoing | Audit PRN order duration and renewal documentation for continued compliance. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | PRN order duration review | Reviews PRN psychotropic order records for genuine 14-day limit enforcement. |
| DOCUMENT | Antipsychotic re-evaluation review | Reviews documentation of genuine physician re-evaluation before any antipsychotic PRN renewal. |
| ASK | Renewal practice interview | Asks prescribing staff how PRN psychotropic renewal genuinely works in practice. |
Supervisor tips
- Ask for a specific, real example of an antipsychotic PRN renewal and its re-evaluation documentation. — A real, traceable example reveals whether re-evaluation is genuine practice, not a formality.
- Check PRN order tracking during a period of staff transition or turnover. — This is where consistent enforcement of the time limit is most likely to lapse.
Evidence base
[19] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, limit as-needed psychotropic orders to a short, defined duration, with as-needed antipsychotic orders specifically prohibited from renewal unless the attending physician or prescribing practitioner evaluates the resident for continued appropriateness.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
4.5
Infection Control Follows a Defined, Facility-Specific Program
Non-Negotiable
The facility maintains an infection prevention and control program specific to its own resident population and physical environment, with a designated, trained infection preventionist — not a generic infection control policy adopted without genuine adaptation to this facility's actual circumstances.
In plain terms: The home has an infection prevention programme written for its own residents and building — surveillance, outbreak plan, antibiotic stewardship, staff training — not a generic policy copied from a hospital.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Care homes are where outbreaks kill: influenza, norovirus, COVID-19, and antibiotic-resistant organisms spread through shared dining rooms, shared staff, and residents who cannot isolate. A hospital infection control policy does not fit: care homes have no isolation rooms, residents wander, and the goal is a home, not a ward. A facility-specific programme addresses: surveillance (which infections, how counted), outbreak recognition and response (when to close, when to notify, how to cohort), antibiotic stewardship (the majority of care home antibiotics are unnecessary and drive resistance), immunisation of residents and staff, hand hygiene, environmental cleaning, and a named infection control lead with training.
What good looks like
- The infection control program genuinely reflects this facility's specific population and environment.
- A designated, trained infection preventionist holds real responsibility for the program.
- The program is genuinely reviewed and updated, not static.
Common failure modes
- A generic infection control policy is adopted without facility-specific adaptation.
- No specific, trained individual holds genuine responsibility for infection control.
- The program hasn't been reviewed or updated in a meaningful timeframe.
Worked example
In practice
A 70-bed care home with an infection control policy adapted from a hospital.
BeforeThe policy referenced isolation rooms the home did not have. No surveillance; infections were treated as they arose. A norovirus outbreak the previous year affected 40 residents and 15 staff before anyone recognised it. Antibiotics were prescribed for every positive urine dipstick. No infection control lead.
ActionA care-home-specific programme was written with the regional infection control team: monthly surveillance of respiratory, GI, urinary, and skin infections; an outbreak plan with triggers (two similar cases in 48 hours), actions (cohorting, enhanced cleaning, visitor guidance, notification); an antibiotic stewardship protocol (no treatment of asymptomatic bacteriuria; McGeer criteria for infection); annual influenza vaccination for residents and staff with tracked uptake; a trained infection control lead; quarterly hand hygiene audit.
AfterThe Monitor reviewed the programme, six months of surveillance data, the outbreak plan, antibiotic prescribing data (urinary antibiotics down 55%), and staff influenza uptake (72%). Verified.
If you are starting from zero — do this first
- Read your infection control policy. Does it describe your building, or a hospital?
- Name an infection control lead and get them trained.
- Start monthly surveillance of the four infection types.
- Write an outbreak plan with clear triggers.
The most common mistake: Treating every positive urine dipstick with antibiotics — most care home residents have bacteria in their urine and no infection.
Self-assessment questions
1. Does the infection control program genuinely reflect this facility's own resident population and physical environment? — Facility-specific adaptation, not a generic policy adopted without genuine customization.
Evidence: Infection control program documentation
Evidence: Infection control program documentation
2. Is there a designated, trained infection preventionist with genuine responsibility for the program? — A specific, trained, designated individual, not an informal or shared responsibility.
Evidence: Infection preventionist designation and training record
Evidence: Infection preventionist designation and training record
3. Is the program genuinely reviewed and updated based on the facility's own actual assessment, not left static? — Real, ongoing adaptation, not a program written once and never revisited.
Evidence: Program review and update record
Evidence: Program review and update record
Common reasons for a PARTIAL answer
- An infection preventionist is designated but their specific training doesn't fully meet defined requirements. — The role's real protective value depends on genuine, adequate training, not designation alone.
- The program addresses common infection risks but doesn't specifically reflect this facility's particular resident population. — Generic coverage of common risks can still miss what's specifically relevant to this facility's actual circumstances.
- Program review happens but doesn't consistently incorporate genuinely current facility assessment data.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current infection control program for genuine facility-specific adaptation. |
| Week 2 | Confirm or establish infection preventionist designation and training against defined requirements. |
| Week 3 | Establish a genuine, scheduled program review process incorporating current facility assessment. |
| Ongoing | Update the infection control program as facility circumstances genuinely change. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Program specificity review | Reviews the infection control program for genuine, facility-specific content, not generic policy. |
| DOCUMENT | Infection preventionist designation review | Reviews the designation and training of the facility's infection preventionist. |
| DOCUMENT | Program update review | Reviews evidence that the program is genuinely reviewed and updated based on facility assessment. |
Supervisor tips
- Ask the infection preventionist to describe a specific risk factor unique to this facility's population. — A specific, informed answer reveals genuine facility-specific engagement, not a generic role.
- Ask when the program was last genuinely reviewed and what changed as a result. — A specific, real answer reveals whether review is genuine practice, not just a stated requirement.
Evidence base
[20] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require facilities to establish and maintain an infection prevention and control program based on the facility's own assessment, with a designated infection preventionist holding specific training.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.