Is Your Hospital Prepared for a Survey on Infection Control CoPs?

Infection Control

About a year ago, the Centers for Medicare & Medicaid Services (CMS) issued its finalized infection control worksheet for surveyors to use in inspections of hospitals. This surveyor worksheet can be used to assess compliance with the infection control Conditions of Participation (CoPs). For the first time, CMS added tracers for a variety of procedures and therapies that Hospitals can use to develop tracer tools to match this surveyor worksheet.

Surveyors Could Show Up Soon

Despite being released early in 2016, few hospitals have a clear idea about what they need to do if a surveyor comes knocking at their door. According to the In other words, anything could happen!

Surveyor interviews can be performed with staff personnel, as well as with patients, their family members and support groups. Preparing your facility comply with CMS’s proposed infection control standards is more important now that you have a blueprint in this worksheet.

What’s Covered in the Worksheet?

The proposed infection control standards are not yet final, but we know they include the requirement to have an antibiotic stewardship program. The core areas that CMS inspectors will examine during an infection control survey include:

  • Infection Prevention Programs covering assessment of available resources, hospital QAPI systems, antimicrobial stewardship, personnel training, etc.
  • General Infection Prevention Elements covering hand hygiene, medications and infusates, personal protective equipment, etc.
  • Equipment Reprocessing, which will look into reprocessing of semi-critical equipment, reusable critical equipment, single-use devices, etc.
  • Patient Tracers, which include indwelling urinary and central venous catheters, ventilator therapy, spinal injection procedures, multiple precautions, surgical procedures, etc.


Get Compliant – Now!

ProfEdOnDemand’s webinar “The CMS Hospital Infection Control Worksheet and Proposed Changes and Antibiotic Stewardship Program” with nurse-attorney and medical-legal consultant Sue Dill Calloway, RN, MSN, JD, answers all your questions about these new requirements from CMS. During this session, Sue covers important memos on infection control issues from CMS, the ISMP IV guidelines and safe injection practices issues. She also goes over the details for the CDC’s vaccine storage and handling toolkit and the CDC’s procedures for cleaning and disinfecting reusable medical devices.


To join the conference or see a replay, order a DVD or transcript, or read more

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