The CMS Hospital Infection Prevention and Control and Antibiotic Stewardship Program - CMS Compliance Requirements 2024

A hospital must have an active infection control program throughout the facility to track, prevent, and control infectious diseases, including Healthcare-Associated Infections, or HAIs.  Additionally, the hospital must have a program for the optimization of antibiotic use through stewardship.  This program will discuss the changes CMS made to the infection control standards in 2019 and the interpretive guidelines developed in July 2022.

The program will cover what a hospital must have in place to comply with the regulation, including qualifications of the infection preventionist, the existence of a hospital-wide antibiotic stewardship program, and following nationally recognized infection control standards.

This webinar will cover the CDC procedures for cleaning and disinfecting reusable medical devices, along with resources for professional training. The Joint Commission standards on the Antibiotic Stewardship Program (ASP) will be briefly discussed.

Learning Objectives:-

• Recall the standard and new interpretive guidelines for infection prevention and control
• Relate key requirements for an infection prevention and control program
• Identify the requirements for the infection preventionist and Antibiotic Stewardship lead
• Describe the incorporation of infection prevention and control and ASP into the QAPI program

Outline

• Introduction
• Conditions of Participation Manual
• Infection Control deficiencies
• CMS Conditions of Participation
• Requirements of an infection prevention program
• Infection preventionist identified and qualified
• Leadership involvement
• ASP program leader's responsibilities
• Hospital QAPI and infection prevention
• Systems to prevent MDRO and correct antibiotic usage
• Responsibilities of preventionist
• Responsibilities of ASP leader
• Unified and integrated programs
• Overview Joint Commission ASP requirements
• CMS memos related to Infection Control
• Joint Commission Standards for Water Management Program
• CDC ASP Core Elements
• CDC Cleaning reusable devices
• CDC Infection Control resources for professionals and training
• CMS Worksheets – briefly

Appendix and Resources

Who Should Attend:-

• Performance improvement director and staff
• Risk management
• Quality staff
• Compliance officer
• Chief nursing officer
• Chief medical officer
• Patient safety officer
• Nurse educator
• Staff nurses
• Nurse managers
• Leadership Staff
• Accreditation staff
• Department directors
• Infection prevention
• Emergency Department Personnel
• Joint Commission Coordinator
• Medical Records
• Quality Improvement personnel
• Risk Manager
• Legal Counsel