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Resident Hand Hygiene in
Nursing Homes

PDF Version of DQA 11-025  (PDF, 82 KB)

Date: October 17, 2011 -- DQA Memo 11-025
To: Nursing Homes NH 17
From: Alfred C. Johnson, Director
Bureau of Licensing, Technology and Education

Juan Flores, Interim Director
Bureau of Nursing Home Resident Care


Otis Woods, Administrator
Division of Quality Assurance

Resident Hand Hygiene in Nursing Homes

The purpose of this memo is to provide nursing homes with information regarding their role and responsibilities related to resident hand hygiene.

Definition of Terms

Alcohol-based hand rub (ABHR)
An alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth.

According to the Centers for Medicare and Medicaid Services (CMS), State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long Term Care Facilities, "grooming" is defined as how a resident maintains personal hygiene to include, but not limited to, washing and drying hands.

Hand Hygiene
According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), hand hygiene is a general term referring to any action of hand cleansing to include, but not limited to, washing hands with soap and water or cleansing hands using an alcohol-based hand rub.

Washing hands with plain or antimicrobial soap and water.

Background Information
The Bureau of Technology, Licensing, and Education within the Division of Quality Assurance (DQA) has received questions regarding resident hand hygiene, specifically, residents who propel their wheelchairs to the dining room for meals not being provided the opportunity and/or not being assisted with handwashing.
It is the expectation of the DQA that nursing homes educate their residents about the importance of hand hygiene, provide resources for hand hygiene to include soap and water and/or alcohol-based hand rubs as appropriate and assist residents who are unable to perform hand hygiene independently.

Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing to include but not limited to; before eating, and after using a bed pan, commode, toilet or urinal.

Nursing home feeding assistants are trained to assist residents to wash their hands before eating. Resident handwashing before meals is included in the following Department approved feeding assistant model curriculums listed below.

  • Assisted Dining: The Role and Skills of Feeding Assistants, by Bonnie Walker, Ph.D., and Claire S. Cole, MA, RN, C., American Health Care Association publication (exit DHS)
  • Assisting with Nutrition and Hydration in Long-Term Care. Hartman Publishing, Inc. (exit DHS)
  • Wisconsin Feeding Assistant Training Curriculum, by the Wisconsin Department of Health Services

After consultation with representatives from both the CDC and CMS, it was agreed that the intent of the CDC and WHO Hand Hygiene Guidelines apply to healthcare workers.

According to the CDC, handwashing remains the best method for resident hand hygiene before meals. However, if soap and water are not available, an alcohol-based hand rub (ABHR) that contains at least 60% alcohol may be used. It is important to note that ABHRs are not effective when hands are visibly dirty and are not effective against all pathogens including clostridium difficile and norovirus. Nursing homes using ABHRs who are experiencing an outbreak from a pathogen that is not eliminated by an ABHR should reconsider its use during the outbreak based on current infection control guidelines.

Information related to Alcohol Based Hand Rub dispensers may be found in the CMS Survey & Certification Letter 05-033 titled Multiple Providers - Adoption of a New Fire Safety Amendment for the Use of Alcohol Based Hand Rubs.

Regulatory Requirements - Grooming

Currently there are three federal regulations that address activities of daily living (ADL) to include grooming.

  1. 42 CFR 483.25(a) (1) (Federal Tag 310) - The intent of this regulation is that the facility must ensure that a resident's abilities in ADLs to include grooming do not deteriorate unless the deterioration was unavoidable.
  2. 42 CFR 483.25(a)(2) (Federal Tag 311) - The intent of this regulation is to stress that the facility is responsible for providing maintenance and restorative programs that will maintain or improve a resident's ADLs, as indicated by the resident's comprehensive assessment to achieve the highest practicable outcome including grooming.
  3. 42 CFR 483.25(a) (3) (Federal Tag 312) - The intent of this regulation is that the resident receives the services needed because he/she is unable to do their own ADL care independently.

Surveyors will make compliance decisions regarding resident hand hygiene based on procedures outlined in the SOM, Appendix PP - Guidance to Surveyors for Long Term Care Facilities and guidance from the CDC.

Regulatory Requirement - Infection Control

Federal regulation 42 CFR 483.65(a)(1) (F441) requires that the facility must establish an Infection Control Program under which it investigates, controls and prevents infections in the facility.

Surveyors will make compliance decisions regarding resident hand hygiene issues related to controlling and preventing infections in the facility using the F441 Investigative Protocol located in the SOM, Appendix PP - Guidance to Surveyors for Long Term Care Facilities and current standards of practice.


CDC Handwashing: Clean Hands Saves Lives

CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings

Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI LTC Facilities


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Last Updated: May 15, 2013