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

Wednesday, 27 September 2017  10:00 AM PDT, 01:00 PM EDT

Training Duration = 120 Min                    Sponsored by Online Compliance Panel

Click Here to register $200.00

Click Here to register and receive CD recording $400.00

The Centers for Medicare and Medicaid Services (CMS) has finalized the surveyor worksheet for assessing compliance with the infection control Conditions of Participation (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.

Learning 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

Why Should You Attend:

This webinar by nurse attorney and medical-legal consultant Sue Dill Calloway, RN, MSN, JD, will discuss important memos on infection control issues from CMS. During the session, Sue will discuss the ISMP IV guidelines and safe injection practices issues. The session will also cover the CDC vaccine storage and handling toolkit and the CDC procedures for cleaning and disinfecting reusable medical devices.

Besides, this program will discuss the proposed infection control standards. This includes a requirement to have an antibiotic stewardship program. The infection preventionist would have to be appointed by the board after approval by the CNO and Medical Executive Committee. There are many additional changes that will be discussed.

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 2017. 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.


  • 49-page final hospital infection control worksheet
  • Proposed changes in 2017
    • Antibiotic stewardship program
    • IP qualified
    • Many proposed changes
  • Infection preventionist identified and qualified
  • Infection control program and resources
  • Infection control policies required (many)
  • Follows nationally-recognized standards (CDC, APIC, etc.)
  • CDC vaccine storage memo
  • PI process
  • CDC vaccines storage and handling
  • ISMP IV push guidelines
  • HAI reported thru PI
  • 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 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 non-critical 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


Sue Dill Calloway is president of Patient Safety and Healthcare Consulting and Education company with 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.