The CMS Hospital Infection Control Worksheet and Final Changes and Antibiotic Stewardship Program

Product Id : HE203
Instructor : Sue Dill Calloway
Jan 21, 2020 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 120 Minutes

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If there is one webinar your hospital should listen to this year it should be this one. If a surveyor showed up at your door tomorrow would your hospital be prepared? The worksheet is used for all validation surveys and certification surveys. You could read the infection control standards and you would be surprised that many things in the worksheet that are not discussed in the standards because CMS requires hospitals to follow all standards of care and standards of practice which include evidence based practice. This is why it is important for the hospital to be in compliance with what is in the 49 page worksheet and to be aware of the proposed changes to the worksheet.

This program will also discuss the many final changes to the infection control standards that went into effect November 29, 2019. (Critical access hospitals were given a 6 month extension to comply with the antibiotic stewardship requirements.) This includes a requirement to have an antibiotic stewardship program. The infection preventionist has to be appointed by the board after approval by nursing leadership and Medical Executive Committee. It sets out the responsibilities of the infection preventionist which should be added to the job description. Hospitals must have a hospital wide antibiotic stewardship program. The requirements will be discussed if a hospital system elects system wide infection control. Hospitals must follow nationally recognized infection control standards. There are some new policies required. There are many additional changes that will be discussed. This webinar will provide many infection control resources especially some recent ones from the CDC.

This webinar will discuss important memos on infection control issues from CMS. It will discuss the ISMP IV guidelines and safe injection practices issues. It will cover the CDC vaccine storage and handling toolkit and the CDC procedures for cleaning and disinfecting reusable medical devices. CMS is hitting hard cleaning of endoscopes, glucose meters, disinfection and sterilization and reusable equipment.

This program will cover in detail CMS infection control worksheet used to assess compliance with the infection control hospital CoPs. The worksheets are used by State and Federal surveyors when assessing compliance with the infection control standards. Infection control is hit hard during the survey and every hospital should have a working familiarity with this important document. This is the first time CMS has ever had tracers. Hospitals should develop tracer tools to match this worksheet. Accreditation organizations may also ask similar questions since all four must apply for deemed status from CMS.

There is also a business case for stepping up enforcement to prevent healthcare associated infections. The Hospital-Acquired Condition (HAC) Reduction Program is in effect for 2020. As part of the Patient Protection and Affordable Care Act, Hospitals that rank in the quartile of hospitals with the highest total HAC scores will have had their CMS payments reduced by 1%.

Citation instructions are provided on the infection control worksheet. Surveyors will follow standard procedures when non-compliance is identified. CMS is now publishing the infection control deficiencies and this will be discussed along with actual information on why hospitals were found to be out of compliance. Although the worksheet is not being used per se at Critical Access Hospitals (CAH), it is highly recommended that all CAH should listen to this webinar since the standards are similar and this is an excellent self assessment tool.


Infection Control Final Worksheet for Hospitals:

  • 49 page final hospital infection control worksheet
  • Proposed changes to the infection control worksheet
  • Final changes in 2020 
    • Antibiotic stewardship program requirements
    • New policies required including control within and between hospital
    • IP appointed by board after approval of MEC and nursing leadership
    • Responsibilities of the infection preventionist
    • Evidenced based guidelines and best practices
    • Many final changes
  • Infection preventionist identified and qualified
  • Infection control program and resources
  • Infection control policies required (many)
  • Follows national recognized standards (CDC, APIC, SHEA, IDSA, etc.)
  • CDC Vaccine storage memo
  • QAPI process 
  • CDC new hospital and LTC resources and modules
  • CDC Vaccines Storage and Handling
  • CDC Guide to Infection Control in Outpatients
  • ISMP IV Push guidelines
  • HAI reported thru QAPI 
  • Training program and must include problems identified
  • Leadership involvement
  • Systems to prevent MDRO and correct antibiotic usage; stewardship
    • Antibiotic orders include indications for use
    • Prompt for clinicians to review 
    • Log of incidents rescinded
    • CAUTI, VAP, SSI, MRSA, D-DIFF, CLABSI are identified and tracers on HAI
    • Process to identify present on admission or POA
    • HCP competency assessments
    • Identify and report and control infections
    • MDRO and contact precautions
  • Module on hand hygiene
  • Infection prevention systems and training
  • Injection practices and sharps safety
  • Environmental cleaning and disinfection
    • Disinfectants used correctly
    • High touch environmental surfaces
    • Reusable noncritical items (BP cuffs, pulse ox probes)
    • Single use devices
    • Laundry requirements
    • Policies and procedures required
  • Point of care devices (blood glucose monitors and INR monitors)
  • Sharps
  • Reprocessing non critical items
  • Single use devices
  • Urinary catheter tracer
  • Central venous catheter tracer
  • Protective environment (bone marrow patients)
  • Isolation contact precautions information provided but not covered
  • Isolation droplet precautions
  • Isolation airborne precautions
  • Critical care module
    • Hand hygiene, sharps safety, injection safety, personal protection equipment, etc.)
  • Ventilator/respiratory therapy tracer
  • Spinal injection practices
  • Invasive procedure module
  • Infection control in the Operating Room
  • Hydrotherapy equipment
  • Infection control tool
  • Infection control questions to ask
  • Questions for employee health nurse in worksheet three
  • Questions for director of education in worksheet one

Who Should Attend?

  • Infection control nurse or coordinator (infection control professionals, now called infection preventionists by APIC and CMS)
  • Chief nursing officer
  • Chief Operating Officer
  • Chief Medical Officer
  • Nurse educator
  • Hospital epidemiologists
  • Infection control committee
  • All nurses and nurse managers
  • PI director
  • Joint Commission coordinator
  • All nursing supervisors and department directors
  • Anesthesiologist and CRNAs
  • Chief medical officers and physicians
  • Risk manager
  • Senior leadership
  • Pharmacists
  • Board members
  • Lab director
  • Patient safety officer
  • Compliance officer
  • Dietitian
  • Physicians and chief medical officer
  • Maintenance director and staff,
  • Housekeeping (Environmental Services)
  • OR manager and OR staff
  • All department directors
  • Antibiotic stewardship members and head
  • Anyone with direct patient care
  • Anyone interested or responsible for infection control
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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