CMS SOM App. PP, Tag F882

The facility must 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)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and

control.

INTENT §483.80(b)

The intent of this regulation is to ensure that the facility designates a qualified individual(s)

onsite, who is responsible for implementing programs and activities to prevent and control

infections.

GUIDANCE

Responsibility for the Infection Prevention and Control Program (including the

Antibiotic Stewardship Program)

The facility must designate one or more individuals as the infection preventionist (IP) who is

responsible for assessing, developing, implementing, monitoring, and managing the IPCP.

The IPCP includes content required in §§483.80(a)(1)-(4), (F880, Infection Prevention and

Control and at F881, Antibiotic Stewardship Program (ASP)). While the IP is responsible for

the IPCP, other staff play important roles in infection prevention and control as well as

antibiotic stewardship. For example, staff must appropriately implement standard

precautions such as hand hygiene and transmission-based precautions. Furthermore, ASP

development should include leadership support and accountability via the participation of the

medical director, consulting pharmacist, nursing and administrative leadership and therefore,

the IP should utilize and work collaboratively with these team members to also implement

the ASP. While an ASP is a team effort, the IP is responsible for ensuring the program meets

the requirements for ASPs (at §483.80(a)(3), F881). The IP should review and approve

infection prevention and control training topics and content, as well as ensure facility staff

are trained on the IPCP

(for further information, see §483.95(e), F945, Infection Control

Training). However, the IP is not required to perform the IPCP training, since some facilities

may have designated staff development personnel.

Primary Professional Training

The IP must be professionally-trained in nursing, medical technology, microbiology,

epidemiology, or other related field.

A professionally-trained nurse must have earned a certificate/diploma or degree in nursing.

A professionally-trained medical technologist (also known as clinical laboratory scientist)

must have earned at least an associate's degree in medical technology or clinical laboratory

science.

A professionally-trained microbiologist must have earned at least a bachelor's degree in

microbiology.

A professionally-trained epidemiologist must have earned at least a bachelor's degree in

epidemiology.

Examples of other related fields of training that are appropriate for the role of an IP include

physicians, pharmacists, and physician's assistants.

Qualifications

The IP must be qualified by education, training, experience or certification. The IP must

have the knowledge to perform the role. The IP should remain current with infection

prevention and control issues and be aware of national organizations' guidelines as well as

those from national/state/local public health authorities (e.g., emerging pathogens). The

facility should ensure the individual selected as the IP has the background and ability to fully

carry out the requirements of the IP based on the needs of the resident population, such as

interpreting clinical and laboratory data. Examples of experience in infection prevention and

control may include, but are not limited to, identification of infectious disease processes,

surveillance and epidemiologic investigation, and preventing and controlling the transmission

of infectious agents. An example of certification is the Certification in Infection Prevention

and Control (CIC®) which is conducted by the Certification Board of Infection Control and

Epidemiology, Inc. (CBIC®) and accredited by the

National Commission for Certifying

Agencies (NCCA).

IP Hours of Work

Designated IP hours per week can vary based on the facility and its resident population.

Therefore, the amount of time required to fulfill the role must be at least part-time and should

be determined by the facility assessment, conducted according to §483.71, to determine the

resources it needs for its IPCP, and ensure that those resources are provided for the IPCP to

be effective. Based upon the assessment, facilities should determine if the individual

functioning as the IP should be dedicated solely to the IPCP. A facility should consider

resident census as well as resident characteristics, types of units such as respiratory care

units,

memory care, skilled nursing and the complexity of the healthcare services it offers as

well as outbreaks and seasonality of infections such as influenza in determining the amount

of IP hours needed. The IP must have the time necessary to properly assess, develop,

implement, monitor, and manage the IPCP for the facility, address training requirements, and

participate in required committees such as QAA.

The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or

perform the IP work at a separate location such as a corporate office or affiliated short term

acute care facility.

Specialized Training in Infection Prevention and Control

Infection prevention and control (IPC) training must be sufficient to perform the role of the

IP. Specialized training in IPC may include care for residents with invasive medical devices,

resident care equipment (e.g., ventilators), and treatment such as dialysis as well as high-acuity conditions. If a facility's resident population changes, the IP should re-evaluate his/her

knowledge and skills, and may need to obtain additional training for the change in the

facility’s scope of care.

An IP must have obtained specialized IPC training beyond initial professional training or

education prior to assuming the role. Training can occur through more than one course, but

the IP must provide evidence of training through a certificate(s) of completion or equivalent

documentation.

CMS recommends specialized training include the following topics:

• Infection prevention and control program overview,

• The infection preventionist’s role,

• Infection surveillance,

• Outbreaks,

• Principles of standard precautions (e.g., content on hand hygiene, personal protective

equipment, injection safety, respiratory hygiene and cough etiquette, environmental

cleaning and disinfection, and reprocessing reusable resident care equipment),

• Principles of transmission-based precautions,

• Resident care activities (e.g., use and care of indwelling urinary and central venous

catheters, wound management, and point-of-care blood testing),

• Water management,

• Linen management,

• Preventing respiratory infections (e.g., influenza, pneumonia),

• Tuberculosis prevention,

• Occupational health considerations (e.g.,

employee vaccinations, exposure control

plan, and work exclusions),

• Quality assurance and performance improvement,

• Antibiotic stewardship, and

• Care transitions.

A free online training is available and was developed by a collaboration between CMS and

the Centers for Disease Control and Prevention (CDC). The "Nursing Home Infection

Preventionist Training Course" is located on CDC's TRAIN website

(https://www.train.org/cdctrain/training_plan/3814

). Other trainings may be available from

entities such as associations, state public health, and universities.

INVESTIGATIVE PROCEDURES

Use the Infection Prevention, Control & Immunizations Facility Task, along with the

above interpretive guidance, when determining if the facility meets the requirements for,

or when investigating concerns related to, compliance with the infection preventionist

requirement at §§483.80(b)(1)-(4) (i.e., role, qualifications, training, and allowed time for

the position).

Instances of the facility not implementing transmission-based precautions when indicated

should be cited at F880. These findings may support citing F882 as well, in which case the

surveyor must also show that the facility did not ensure requirements at §483.80(b) were met.

For example, F882 should be cited if the IP was not available to assist staff on multiple

occasions with their questions on when transmission-based precautions should be initiated for

a resident due to lack of sufficient time to perform the IP role, and this led to noncompliance

with F880.

The facility may be cited at an infection control tag such as F880, but not at F882. For

example, F882 should not be cited if all requirements at §483.80(b) are met, but a staff

member did not clean and disinfect reusable resident care equipment (e.g., blood pressure

cuff, thermometer) after use on a resident on transmission-based precautions and it was then

used on the next resident, despite proper policies and procedures, staff training, and process

surveillance of staff practices addressing this concern.

Conversely, the facility can be cited at F882 although not at F880, F881, or F945 in cases

where a surveyor's investigation began with an infection control concern leading to a review

of the IP, but in the end did not result in evidence of noncompliance at another infection

control tag (e.g., F880, F881) or F945. For example, during the investigation, the surveyor

found through record review that the IP did not have specialized training.

Surveyors should utilize the Quality Assessment and Assurance (QAA) and Quality

Assurance and Performance Improvement (QAPI) Plan Review Facility Task to determine

compliance with §483.80(c), IP participation on QAA committee.

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F882, the surveyor’s investigation will generally show that the

facility failed to ensure that the IPCP was overseen by a qualified individual, who:

• Meets the requirement for professional training; or

• Adequately assesses, develops, implements, monitors, and manages the IPCP; or

• Has the appropriate knowledge and skills to care for the IPC needs of the facility's

resident population and to be responsible for the IPCP; or

• Has time to perform IP responsibilities; or

• Performs IP duties in the facility; or

• Completed specialized training in IPC.

DEFICIENCY CATEGORIZATION

An example of Level 4, immediate jeopardy to resident health and safety includes,

but is not limited to:

• The facility failed to ensure the IP was qualified by education, training,

experience or certification to identify a gastrointestinal outbreak in the facility and

implement appropriate control measures. Surveyors identified that the IP did not

ensure that appropriate control measures (e.g., transmission-based precautions,

environmental cleaning and disinfection) and reporting to public health occurred.

As a result, several residents became seriously ill with diarrheal illnesses resulting

in dehydration.

An example of Level 3, actual harm that is not immediate jeopardy includes, but is

not limited to:

• The facility failed to ensure the IP implemented the IPCP appropriately for a case

of pediculosis (i.e., head lice) and the resident's roommate also became infested.

Per the IPCP and CDC recommendations, the resident should have been placed on

contact precautions until 24 hours after the application of an effective treatment.

The IP participated in an interview and confirmed that she was aware of the

diagnosis but did not ensure contact precautions were initiated.

An example of Level 2, no actual harm with potential for more than minimal harm,

that is not immediate jeopardy includes, but is not limited to:

• The facility failed to ensure the IP was performing the duties of the position and

was qualified to perform the role. The IP did not ensure the facility had an

antibiotic stewardship program. Based on record review, the facility could not

provide documentation for an antibiotic stewardship program. During the

interview, the IP demonstrated a lack of understanding of an effective program

and how to implement an antibiotic stewardship program. Additionally, during

the interview, the IP confirmed that she did not have training in antibiotic

stewardship.

An example of Level 1, no actual harm with potential for minimal harm includes,

but is not limited to:

•

The facility failed to ensure the IP had appropriate time to perform IP responsibilities.

Record review and interview(s) revealed that the IP failed to ensure that the IPCP

was reviewed annually. The IP verified that she did not have enough time onsite

to update the IPCP by its annual deadline and two months had passed since an

update was required. There were no infection control findings outside of annual

review and documentation.

POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION

• F838: for concerns related to the facility assessment;

• F867: for concerns related to the QAA committee’s responsibility to identify or

correct quality deficiencies, which may include systemic infection control concerns;

• F868: for concerns related to the QAA committee to include the IP's participation;

• F880: for concerns related to infection prevention and control;

• F881: for concerns related to the antibiotic stewardship program; and

• F945: for concerns related to staff training on the standards, policies, and

procedures of the infection prevention and control program.