Infection Control and Barrier Precautions
Frequently Asked Questions
For individuals who are required by law to report their completion of approved course work in infection control and barrier precautions.
- Who must complete infection control course work and
where do these professionals report compliance with this
The Education Law requires that, on or before July 1, 1994 and every four years thereafter, every dental hygienist, dentist, licensed practical nurse, optometrist, podiatrist, and registered professional nurse practicing in New York State complete approved infection control and barrier precautions course work appropriate to the professional's practice. The goal of this law is to prevent the transmission of the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) in the course of professional practice. Each aforementioned professional must document compliance to the Education Department at the time of his/her first registration after July 1, 1994 and every subsequent reregistration.
Physicians, Physician Assistants (PAs), and Specialist Assistants (SAs), while needing to meet the same requirement and deadlines, must document their completion of approved course work either to the Department of Health-regulated health care facilities at which they are credentialed or, if not so credentialed, to the New York State Department of Health. Such individuals' compliance with the course work requirement has no effect on the Education Department's licensure or registration in these three professions. Physicians, PAs, and SAs should direct any questions to:
Bureau of Healthcare-Associated Infections
Healthcare Epidemiology and Infection Control Program
New York State Department of Health
- What is approved course work? Does it have a specified core
Approved course work is that which is received during the four years prior to attestation either from providers designated by the State Education Department (SED) or the Department of Health (DOH) or in an SED-registered professional program completed subsequent to September 1993. Approved infection control course work must contain, at a minimum, the following six core elements:
- Licensee's responsibility to adhere to scientifically accepted principles and practices of infection control and to monitor the performance of those for whom the professional is responsible;
- Modes and mechanisms of transmission of pathogenic organisms in the health care setting and strategies for prevention and control;
- Use of engineering and work practice controls to reduce the opportunity for patient and health care worker exposure to potentially infectious material;
- Selection and use of barriers and/or personal protective equipment for preventing patient and health care worker contact with potentially infectious material;
- Creation and maintenance of a safe environment for patient care through application of infection control principles and practices for cleaning, disinfection, and sterilization; and
- Prevention and control of infectious and communicable diseases in health care workers.
- I am a licensed dentist. May I take an approved infection
control course designed for optometrists?
No. The Law requires that course work must be appropriate to the professional's practice. Thus, a dentist needs to take course work specific to the dental setting, which may differ significantly from an optometric practice. The same rule holds for each of the different professions. You may, however, find that some course work has been approved for multiple professions. For example, a registered professional nurse who only works in a dentist's office may complete approved course work offered by the Dental Society of the State of New York.
- Does the approved course work have to contain a specified
number of hours?
No. Staff from SED and DOH, assisted by an advisory group comprised of representatives from the professions affected by this law and experts in the field of infection control, collaborated to develop a curriculum which would contain the minimum material that is applicable to all health professions and health care settings. Although six core elements were identified (each of which must be covered substantially), it is anticipated that the course work will be tailored to the specific professional audience. Neither law nor regulations specify a minimum time requirement; however, we anticipate that a minimum of two to four hours will be needed to cover the content. Since there is no requirement that training be offered in a single session, some providers may offer a series of programs. Indeed, approved distance-learning course work is now available for some professions, combining video or audiocassettes with study materials and a send-in-test.
- How are approved course work providers identified?
The Regulations of the Commissioner of Education were amended, effective August 16, 1993, to set standards for the approval of infection control course work. Such course work or training must be offered by a provider that falls into one of three categories:
- a Department of Health regulated facility;
- a college or university authorized to offer programs leading to licensure or providing post-licensure education in a profession affected by this requirement;
- or an organization or government entity that has as a purpose the provision of education or training on health care related issues to licensed professionals subject to requirements of this law.
The Department of Health approves course work providers at DOH-regulated facilities and those organizations that seek to offer courses primarily to physicians, physician assistants, or specialist assistants. The Education Department approves course work providers for all other professionals affected by this law. When reviewing provider applications, both agencies consider the proposed curriculum, instructors' competence, and the organization's facilities, equipment and other resources.
- If I am to document compliance to the Education Department,
how and when do I report my completion of approved infection control
At the time of your first licensure or reregistration application after July 1, 1994 (and each subsequent reregistration thereafter), you will be required to attest to your compliance with this requirement.
- I understand that upon completion of State-approved course
work, I will receive a certificate of completion from the course work
provider. Should I send that certificate of completion to the Education
Department along with my registration application?
No, do not send your certificate of completion or a copy of the document to the Education Department. You should keep this important certificate and a photocopy of your attestation form in your personal files for at least four years after the date of your attestation. If compliance is based on completion of a Department-registered professional program subsequent to September, 1993, you will not have a separate certificate of completion; your graduation documents will prove your program completion. If you are selected for a Department audit, you will be required to provide all appropriate documentation.
- I took an OSHA course in infection control. Can this be considered
the equivalent of a Department-approved course?
No. Courses offered to fulfill only the regulations of the Federal Occupational Safety and Health Administration (OSHA) do not include all six core elements that must be contained-at a minimum-in either Department-approved course work or course work which could be deemed to be equivalent.
- I live outside New York State and never practice my licensed
profession within the State of New York. However, I wish to retain
my New York State license and registration. Do I have to take the
approved infection control course work?
No. The Education Law states only that certain licensed health professionals practicing in the State must document their completion of the required training to the Department. Therefore, in section 2(a) of the attestation form (Form 1IC 11 KB), you may attest that you will not engage in the practice of your profession within New York State during the dates of your next registration period. This will exempt you from the course work requirement.
If you return to practice in this State, you must:
- Inform the Department of your return within thirty (30) days;
- complete the required course work within ninety (90) days of the change in practice, and
- within a reasonable time, notify the Department in writing of your compliance with this requirement.
- I live in New York State, but I will not practice my profession
for such reasons as unemployment or retirement. However, I still want
to maintain my New York State registration. Must I take infection
control course work?
No. Again, if you can attest at the time of your application for licensure or registration that you will not be engaged in professional practice within New York State during the ensuing registration period, you may claim exemption from the course work requirement, as outlined in question 10. However, if you return to active practice in the State, you must follow the guidelines described in the previous answer.
- I want to claim exemption from taking the infection control
course work because the nature of my practice doesn't require the
use of infection control measures. How can I be sure that I qualify
for this exemption?
One way to assure that your practice does not require the use of infection control measures is to ask yourself three questions:
In the course of my professional practice:
- Do I have direct contact with one or more patients or clients in any setting-hospital, private office, home care, day care, counseling, or nursing home?
- Do I have direct contact with materials potentially contaminated by pathogens?
- Do I supervise others who have direct contact with patients or materials potentially contaminated by pathogens?
If you can answer NO to all three questions, then you do not need to take the infection control course work and you may claim exemption in section 2(b) of the attestation form. However, if you answer yes to any one or more questions or you are unsure of the answer, you should complete course work.
- I will graduate soon from a professional program registered
by the New York State Education Department. Do I still need to take
infection control course work?
No, if you graduated after September, 1993 and you completed a registered professional program that prepares graduates for licensure in the affected health professions. You may attest compliance with this requirement at the time of your application for licensure or reregistration.
- I am a recognized expert in the field of infection control.
May I be exempt from this course work requirement?
Unfortunately, no. The Law does not recognize professional expertise as a basis for exemption from the requirement.
- How does the Department plan to audit a licensee's compliance
with this requirement?
The Department will conduct periodic audits of a sample of licensees who claim compliance with, or exemption from, this requirement. Those audited will be asked to provide adequate documentation, such as is described in the answers to questions 7, 8, and 10.
- What will happen if I am selected for audit and my documentation
is incomplete or inadequate?
A reviewer will assess your documentation to determine your compliance with, or exemption from, this requirement. If you are determined to be in noncompliance, a judgment will have to be made as to whether there is clear evidence of a good faith effort to comply with the law. If there is, you may be directed to take course work from an approved provider by a given date. Absent clear evidence of good faith, noncompliance may be deemed professional misconduct. Professional misconduct is punishable by a variety of means, including fine, censure, or suspension or revocation of the professional's license.