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

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? 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.

Infection control issues related to COVID-19 will be discussed. This includes several memos from CMS included the targeted infection control surveys and self assessment. The CDC also has many resources and recommendations on COVID-19 that will be covered.

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 which is already in effect. CAHs have 25 new tag numbers in infection control.) 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.

Healthcare risk & compliance expert, Laura A. Dixon, BS, JD, RN, CPHRM, 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.

Session Agenda

  • 49 page final hospital infection control worksheet

  • Proposed changes to the infection control worksheet

  • COVID-19 infection control issues; CMS memos and CDC

  • 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

  • Environmental cleaning and disinfection

  • Point of care devices (blood glucose monitors and INR monitors)

  • Urinary catheter tracer

  • Central venous catheter tracer

  • Protective environment (bone marrow patients)

  • Isolation contact precautions information provided but not covered

  • 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

  • How this wil

Session Objectives

  • Discuss that CMS has a final infection control worksheet

  • Recall that the infection control worksheet has a tracer on indwelling urinary catheters

  • Describe what CMS requires for safe injection practices and sharps safety

  • Recall that the infection control worksheet has a section on hand hygiene tracer

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,

  • Dietician,

  • 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

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker. In case you miss the live webinar due to an emergency, we will send you the copy of recordings for your unlimited watching. 

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Webinar Information

Date / Time : 21 Oct 2020 @ 01:00 PM EST

Duration : 120 Minutes

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Speaker Detail

Laura A. Dixon, BS, JD, RN, CPHRM

Alt Text Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states.  Such services included creation of and presentations readmore...


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Webinar Information

Date / Time : 21 Oct 2020 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at