Staff must be informed and competent in following proper infection control practices. Systems for educating team members and for ensuring that they understand and apply the information properly while performing their job duties is essential. In 2022, 4027 facilities were surveyed with a total of 5776 deficiencies related to F-Tag 880 Infection Control. Many of these tags stemmed, in part, from ineffective education. How does your Infection Prevention and Control Training Program measure up?

According to CMS guidelines, a facility must develop and implement written policies and procedures for the provision of infection prevention and control. These IPCP policies and procedures must include, at a minimum…education and competency assessment. Facilities must ensure staff follow the IPCP’s standards, policies and procedures. Therefore, staff must be informed and competent. Knowledge and skills pertaining to the IPCP’s standards, policies and procedures are needed by all staff in order to follow proper infection control practices (e.g., hand hygiene and appropriate use of personal protective equipment) while other needs are specific to particular roles, responsibilities, and situations (e.g., injection safety and point of care testing).

So how does a facility ensure that their staff is both informed AND competent?

Staff should be educated upon hire and on an ongoing basis to ensure compliance with infection control practices with competency evaluations at least annually. Educate staff when facility policies and procedures are revised and with updates in practice standards, or with any outbreak. Critical training topics include:

      • Routes of disease transmission
      • Hand Hygiene
      • Sanitation procedures
      • Multi Drug Resistant Organisms (MDROs)
      • Transmission Based Precautions
      • OSHA required education
      • Antibiotic Stewardship

In addition, the most effective Infection Prevention & Control (IPC) training programs target training to the job duties that individual personnel will be performing. For instance, the housekeeper doesn’t need to know appropriate Injection safety practices, and business office personnel do not typically need to know how to disinfect the kitchen counter surfaces after meal service. While education on the general tenets of the program, such as handwashing, general transmission-based precautions guidelines, and personal protective equipment use, are necessary for all staff; beyond these general IPC practices, the focus of education should be on job-specific concerns.

Define Role Specific IPC Responsibilities

The staff development coordinator, in conjunction with the nursing administration and department heads, should make a thorough list of tasks performed by staff in each department where Infection Control practices must be addressed in order to develop individualized IPC educational programming that addresses those responsibilities in a manner consistent with standards of care and facility-specific procedures.

Competency Assessment

Once the listing of tasks by department and the educational programming for each has been developed, a means for assessing competency must be instituted. Competency may be assessed through return demonstration, competency focused post testing, case study activities, random audits of task performance, having the staff member “teach” you how to perform the task, or any other method which will show the person has the knowledge and skill to perform the task adequately. Documentation of competency assessments is critical, with competency checks performed on a schedule which ensures that monitoring for competent performance at least annually. If performance concerns are observed, then an individualized Performance Improvement Plan should be instituted, with more frequent monitoring put in place.


Routine rounds by the IP (Infection Preventionist), Staff Development Coordinator, and Department Heads should also be completed to monitor for any lapses in performance and identification of need for further education or training. The CDC has made 19 Quick Observation Tools available to assist with monitoring of high-risk areas. “On the Spot” education is critical to address lapses at the time they occur. Staff completing compliance rounds should be prepared with the tools necessary to intervene in real time as lapses are noted, as education given in the moment is always more effective than waiting hours or days to re-visit the issue. Documentation of re-education should be maintained with trending of specific staff, shifts, or departments with recurrent issues maintained, in order to provide targeted remedial education and development of a Performance Improvement Plan to address lapses in competency. During times of increased Infection Control concerns, such as an outbreak in the facility or community, more frequent monitoring of IPC practices should be instituted with reassessment of staff competencies for relevant IPC practices.

A strong staff education program for infection control will ultimately help to keep your staff and residents healthy. Good planning, monitoring, re-assessment, and staff involvement in the program will assist your facility in meeting CMS requirements for F880 and provide your facility with a well-educated and capable workforce.

Make plans to join us September 20th, 2022 for Infection Control Focused Training & Competency Assessments as part of the monthly Proficient Infection Preventionist series. Also, it’s not too late to register to join us Thursdays through October 6, 2022 for Unpacking the RoP Interpretive Guidance as we discuss implementation essentials to prepare for survey updates effective October 24th. The September 29th session addresses Interpretive Guidance for Infection Control, among other updates. Recordings of past sessions are available with the full series purchase.


Judy Caffrey, RN
Clinical Consultant

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