The CMS Final Infection Control Worksheet for Hospitals

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

Stay Prepared Before a Validation Surveyor Knocks Your Door!


CMS just issued the final infection control worksheet for hospitals. Since this is new, many hospitals have not heard about it and are not aware of what they need to do to prepare should a surveyor coming knocking at their door. It is very comprehensive and in fact the first time CMS has ever done tracers such as the foley catheter tracer, central line tracer, hand hygiene etc. It is 49 pages long and has some new areas and questions to ask that have never been surveyed before. Also CMS is hitting the infection control standards harder because of a recent study that shows the high number of healthcare associated infections and the cost to Medicare. CMS received a 50 million dollar grant so many of the surveyors just went through infection control training. HHS is using up to one billion dollars to help reduce infections and adverse events in hospitals. There were some recent changes to the infection control standards also.

The surveyor worksheet for the assessment of compliance with the infection control Conditions of Participation (CoPs) has been finalized by the CMS. These worksheets are used by state and federal surveyors on all survey activates when assessing compliance with the infection control standards. Infection control is the focal point during a validation survey and every hospital should have a full working familiarity with this important document. With the new changes, hospitals should now also develop tracer tools to match this worksheet. Hospitals may also face similar questions from accreditation organizations to get deemed status from CMS.

Attend this webinar by expert speaker Sue Dill Calloway, RN, MSN, JD, and stay prepared for any visit by a surveyor, who might show up at your door any time for a validation survey. Sue will help you get a better understanding of the CMS hospital infection control worksheet. There is a business case for stepping up enforcement to prevent healthcare associated infections since hospitals with the highest total HAC scores will have their CMS payments reduced by 1% according to the Hospital-Acquired Condition (HAC) Reduction Program that went into effect for fiscal year 2015 and 2016.

This session will also discuss the infection control deficiencies published by the CMS 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 the same and this is an excellent self-assessment tool.

Session Highlights:

  • Review the 49-page final hospital infection control worksheet
  • Infection preventionist identified and qualified
  • Identify infection control program and resources
  • Discuss required infection control policies for hospitals
  • Guidance on following national recognized standards (CDC, APIC, etc.)
  • Training program and identification of must include problems
  • Discuss that the infection control worksheet has a tracer on indwelling urinary catheters
  • Describe what CMS requires for safe injection practices and sharps safety
  • Discuss that the infection control worksheet has a section on hand hygiene tracer
  • Best practices for physicians, nurses and other healthcare professionals
  • Review the deficiency reports issued by the CMS in this area
  • Practice gaps and why these gaps exist
  • How to drive leadership involvement

Session Agenda:

  • Review the PI process
  • How HAI is reported through PI
  • Systems to prevent MDRO and correct antibiotic usage; stewardship
    • Antibiotic orders include indications for use
    • Prompt for clinicians to review
    • Log of incidents (may rescind standard in 2012)
    • CAUTI, VAP, SSI, MRSA, D-DIFF, CLABSI are identified and new 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
  • 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
  • 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
  • Dietician
  • Physicians and chief medical officer
  • Maintenance director and staff
  • Housekeeping (Environmental Services)
  • OR manager and OR staff
  • All department directors
  • Anyone with direct patient care
  • Anyone interested or responsible for infection control

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

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...   More Info
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