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CMS Hospital Infection Control Worksheet – Webinar

December 3 @ 9:00 am - 11:00 am

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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? 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.

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.


  • 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), CNO,COO, CMO, nurse educator, hospital epidemiologists, all nurses and nurse managers, PI director, joint commission coordinator, all nursing supervisors and dept. directors, anesthesiologist and CRNAs, risk manager, senior leadership, pharmacists, board members, lab director, patient safety officer, compliance officer, dietician, physicians, maintenance director and staff, environmental Services, OR manager staff, all department directors, antibiotic stewardship members, and anyone with direct patient care.


$200 per facility/hospital