Nursing facilities will be required to designate one or more individual(s) as the Infection Preventionist(s)

The Phase 3 SNF §483.80(b) Infection Preventionist requirements must be in place by November 28, 2019. As part of the new requirements, nursing facilities will be required to designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The IP must:

  • §483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;
  • §483.80(b)(2) Be qualified by education, training, experience or certification;
  • §483.80(b)(4) Have completed specialized training in infection prevention and control; and
  • §483.80(b)(3) Work at least part-time at the facility***

***On 7/18/2019, CMS released the proposed rule that revises the LTC requirements of participation. In the proposed rule they are proposing to remove the requirement that the infection preventionist (IP) work at the facility “part-time” and will instead require that the facility must ensure that the IP has sufficient time at the facility to meet the objectives of its IPCP.

In the proposed rule, CMS is not proposing to delay the implementation of the Phase 3 requirements related to the Infection Preventionist. Nursing facilities will be required to have the Infection Preventionist role filled with an individual who has completed the required training by November 28, 2019.

CMS and the CDC collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting that is designed to meet the requirement related to the specialized training in infection prevention and control. The training is available here.

According to CMS, “The course includes information about the core activities of an infection prevention and control program, with a detailed explanation of recommended practices to prevent pathogen transmission and reduce healthcare-associated infections and antibiotic resistance in nursing homes. Additionally, this course provides helpful implementation resources (e.g., training tools, checklists, signs, and policy and procedure templates). The course is approximately 19 hours long and is made up of 23 modules and submodules. The modules can be completed at any time, in any order, and over multiple sessions, depending on the learner’s schedule. In order to receive continuing education for the course and a certificate of completion, learners must complete all modules and pass a post-course exam.”

To prepare for this requirement, ensure that you have at least one individual assigned as your Infection Preventionist, who meets the qualifications and has completed the specialized training. Consider assigning additional individuals at your facility, who meet the educational requirements, at to complete this specialized training. This will ensure that you remain in compliance in the event of turnover in your IP position, but will also provide additional knowledge to these individuals to enhance infection prevention practices in your facility.

In FY2018, there were 41 Immediate Jeopardy citations nationally at F880- Infection Prevention & Control. This highlights the significant risks that your facility and residents may face if you fail to ensure your IP is competent to meet the needs of your resident population. As you prepare for the upcoming Phase 3 Requirements of Participation, it is an excellent time to evaluate your current Infection Prevention and Control program to identify weaknesses and put measures in place to protect your facility and residents from adverse events and potential negative survey outcomes.

Get Proactive’s on-demand training covering Phase 3 RoP: Next steps for the Infection Preventionist

This 1.25 hour session will assist SNF providers in understanding the new requirements related to Infection Preventionists. A review of regulatory requirements regarding Infection Preventionist with an analysis of the essential duties and requirements related to this new position will be emphasized. Click here to get all the details and download this resource in our shop.

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Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

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