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

Part 1 of 2 will be 12:00 AM to 2:00 PM EST on December 19, 2017

Description:

If there is one webinar your hospital should listen to this year it would be this one. If a surveyor showed up at your door tomorrow would you be prepared? The worksheet is used for all validation surveys and certification surveys. You could also read the infection control standards and you would be surprised that many things in the worksheet 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 program will also 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.

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 the CDC vaccine storage and handling toolkit and the CDC procedures for cleaning and disinfecting reusable medical devices.

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.

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 seat 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.

Agenda of the Session:

Infection Control Final Worksheet for Hospitals:-

• 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 at 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 noncritical 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

Objectives of the Session:

• 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

The CMS Hospital Interpretive Guidelines on Infection Control and Antibiotic Stewardship Program:

Part 2 of 2 will be on Thursday, December 19 at 2:30 PM to 4:30 PM EST

This program will cover the current CMS infection control standards in detail. It will also cover the TJC antibiotic stewardship program requirements and the CMS proposed infection control standards which also includes a requirement for an antibiotic stewardship program. This will include the CDC Core elements for hospitals and outpatient departments regarding their antibiotic stewardship program. This will include some significant proposed changes to the infection control standard from the Hospital Improvement Act. This includes a requirement to have the board appoint the infection preventionist (IP) with the approval of the CNO and Medical Executive Committee. This program will discuss the CDC and FDA update review procedure for cleaning, disinfecting, and sterilizing reusable medical devices and the CDC vaccine storage and handling toolkit.

Infection control is a really important issue and should be a top priority for hospitals. It can cost hospitals money if it is not done right! CMS has hospital-acquired conditions (HACS) in which there is no additional payment to hospitals for certain infections. The Hospital-Acquired Condition (HAC) Reduction Program is in effect and 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 their CMS payments reduced by 1%.

Common deficiencies in infection control will be discussed. The number of infection control deficiencies has gone up significantly and this should be on the radar screen of every hospital. Tips to prevent getting a deficiency will be covered.

This program will also discuss recent CMS memos on infection control such as the safe injection practices, CRE, and insulin pen memos. It will include an important memo about four unsafe injection practices. If any of these four infection control breaches occur it must be reported to the state authorities for public health assessment and management. These are four of the ten CDC safe injection practice requirements.

CMS requires hospitals to follow standards of care. ISMP has published 26 pages of guidelines on IV push drugs for adults which will be discussed. CMS specifically mentions ISMP to the CoPs. The CDC guidelines on vaccine handling and storage will be covered.

Hospitals that receive Medicare reimbursement have to comply with the CMS interpretive guidelines on infection control. Every hospital needs to ensure their infection control preventionist is familiar with these guidelines. The program will cover in detail the 12-page requirements.

Infection control is a very important area in today’s healthcare environment. The CDC estimates that there are about 1.7 million healthcare-associated deaths in America every year and 100,000 deaths. It is estimated that healthcare-acquired infections (HAIs) incur nearly $20 billion in excess healthcare costs each year. This is also why HAIs is a top priority for the US Department of Health and Human Services.

Both CMS and TJC have issued memos on steam sterilization and flash sterilization (now called immediate use steam sterilization) which will be discussed along with memos on cleaning of scopes. Cleaning of glucose meters between patients, single-use lancets, cleaning of scopes and laryngoscopes, hand hygiene, single and multi-dose vials are just some of the hot issues being covered during the survey process.

Hospitals have to use the CDC system to report central line infections for ICUs. Safe injection practices are important and hospitals should have a policy and procedure on this. This should include the ten CDC safe injection practices. Every hospital should ensure staff is trained on the safe injection practices policy. CMS also issued survey memos on safe injection practices, infection control breaches, two on humidity, three on EBOLA and one on CRE and ERCPs.

Hospitals need to have a good infection control practices in place or face denial of reimbursement. CMS had adverse events or hospital-acquired conditions (HACs) in which hospitals would get no additional reimbursement and several involve infection control issues. Several of the 29 Never Events are infection control issues and many insurers are trying to put into hospital contracts that the hospital cannot bill for these. Surveyors can cite hospitals for being out of compliance with the hospital conditions of participation (CoPs). Therefore, it is important that your infection prevention and staff be up to date on this essential information.

Additional resources will be provided which include proposed changes to the hospital infection control worksheet.

Agenda of the Session:

• Who needs to follow
• ISMP IV Push Guidelines
• 2017 Proposed changes to infection control
  • Antibiotic stewardship program requirement
  • IP appointed by the board and approved by MEC and CNO
  • Changes in the IC standards
  • Compliance with standards of care
• Importance of infection control today
• CMS Infection Control Breaches Memo
• CRE and cleaning of scopes
• Humidity memos
• CDC 2016 Vaccine Storage and Handling
• CDC November 2015 Outpatient Guidelines
• CMS Safe Injection Practices memo
• CMS Insulin Pen memo
• CMS infection control surveys
• CDC HAI and deaths,
• CMS final worksheet on infection control
• CMS Memo to Surveyors,
• Most recent changes to the infection control standards
• CMS Manual
• Tag number A-0747 through 750 and 756,
• Active program for prevention and control,
• Includes infection and communicable diseases,
• Definitions,
• Applicability to housekeeping and maintenance,
• Dietary surveillance areas,
• Following standards of care; APIC, CDC, OSHA, AORN, SHEA,
• Documenting surveillance activities,
• Participation in PI projects and NHSN,
• CDC system and tracking MRSA and VRE,
• Challenges in MDROs (multi-drug resistant organisms),
• Ambulatory and ED areas,
• CDC’s HICPAC (federal advisory committee),
• Isolation guidelines, prévention pneumonia etc.,
• Bioterrorism and emergency preparedness,
• Compliance with OSHA,
• Survey procedure by CMS surveyors,
• Required policies for infection control,
• Resources for infection control must be adequate,
• System to identify, report, investigate and control infection,
• HAI and community-acquired infections,
• Infection control officer’s responsibilities,
• Log of incidents,
• Keeping up with the literature
• Resources for complying with standards
• HHS video on Preventing HAI every practitioner should see
• CDC guidelines on intravascular catheters
• CMS revised CoP on IV medications and blood transfusions
• HHS HAI Video every healthcare provider should see Partnering to Heal
• CDC Guide and Checklist for Outpatient Setting; Minimum Expectations for Safe Care
• CMS Plans Infection Control Inspections of Hospitals
• Bonus slides on the proposed changes to the infection control worksheet and the 2017 pilot program

Objectives of the Session:

• Recall that there are many policies and procedures required by CMS in the area of infection control,
• Describe what the Joint Commission has antibiotic stewardship program requirements,
• Discuss that CMS requires that the national standards of care and practice must be followed such as those from the CDC, SHEA, APIC, OSHA, and AORN,
• Describe that all glucose meters should be cleaned after each use,
• Recall that CMS requires mandatory education in infection control
• Recall that a clean needle and syringe should be used each time under the safe injection practices memo issued by CMS

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.
• 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,
• Maintenance director and staff,
• Housekeeping (Environmental Services),
• OR manager and OR staff,
• Anesthesia staff
• Anyone interested or responsible for infection control.