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Who should attend The CMS Hospital Infection Control Worksheet and Proposed Changes and Antibiotic Stewardship Program
Anyone interested or responsible for infection control
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The CMS Hospital Infection Control Worksheet and Proposed Changes and Antibiotic Stewardship Program  

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Seminar Summary:

The Centers for Medicare and Medicaid Services (CMS) has finalized the surveyor worksheet for assessing compliance with the infection control Conditions of Participation (CoPs). The worksheets are used by State and Federal surveyors when assessing compliance with the infection control standards. Infection control is hit hard during the survey and every hospital should have a working familiarity with this important document. This is the first time CMS has ever had tracers. Hospitals should develop tracer tools to match this worksheet. Accreditation organizations may also ask similar questions since all four must apply for deemed status from CMS. (see full course description)

 
 

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Training Course Syllabus:


CMS Hospital Infection Control Worksheet and Proposed Changes and Antibiotic Stewardship Program Webinar

Objectives of the Presentation

Discuss that CMS has a final infection control worksheet
Recall that the infection control worksheet has a tracer on indwelling urinary catheters
Describe what CMS requires for safe injection practices and sharps safety
Recall that the infection control worksheet has a section on hand hygiene tracer

Why Should you Attend

This webinar by nurse attorney and medical-legal consultant Sue Dill Calloway, RN, MSN, JD, will discuss important memos on infection control issues from CMS. During the session, Sue will discuss the ISMP IV guidelines and safe injection practices issues. The session will also cover the CDC vaccine storage and handling toolkit and the CDC procedures for cleaning and disinfecting reusable medical devices.

Besides, this program will discuss the proposed infection control standards. This includes a requirement to have an antibiotic stewardship program. The infection preventionist would have to be appointed by the board after approval by the CNO and Medical Executive Committee. There are many additional changes that will be discussed.

There is also a business case for stepping up enforcement to prevent healthcare associated infections. The Hospital-Acquired Condition (HAC) Reduction Program is in effect for 2017. As part of the Patient Protection and Affordable Care Act, Hospitals that rank in the quartile of hospitals with the highest total HAC scores will have had their CMS payments reduced by 1%.

Citation instructions are provided on the infection control worksheet. Surveyors will follow standard procedures when non-compliance is identified. CMS is now publishing the infection control deficiencies and this will be discussed along with actual information on why hospitals were found to be out of compliance. Although the worksheet is not being used per se at Critical Access Hospitals (CAH), it is highly recommended that all CAH should listen to this webinar since the standards are similar and this is an excellent self assessment tool.

Areas Covered

49-page final hospital infection control worksheet
Proposed changes in 2017
Antibiotic stewardship program
IP qualified
Many proposed changes
Infection preventionist identified and qualified
Infection control program and resources
Infection control policies required (many)
Follows nationally-recognized standards (CDC, APIC, etc.)
CDC vaccine storage memo
PI process
CDC vaccines storage and handling
ISMP IV push guidelines
HAI reported thru PI
Training program and must include problems identified
Leadership involvement
Systems to prevent MDRO and correct antibiotic usage stewardship
Antibiotic orders include indications for use
Prompt for clinicians to review
Log of incidents rescinded
CAUTI, VAP, SSI, MRSA, D-DIFF, CLABSI are identified and new tracers on HAI
Process to identify present on admission or POA
HCP competency assessments
Identify and report and control infections
MDRO and contact precautions
Module on hand hygiene
Infection prevention systems and training
Injection practices and sharps safety
Environmental cleaning and disinfection
Disinfectants used correctly
High touch environmental surfaces
Reusable non-critical items (BP cuffs, pulse ox probes)
Single use devices
Laundry requirements
Policies and procedures required
Point of care devices (blood glucose monitors and INR monitors)
Sharps
Reprocessing non-critical items
Single use devices
Urinary catheter tracer
Central venous catheter tracer
Protective environment (bone marrow patients)
Isolation contact precautions information provided but not covered
Isolation droplet precautions
Isolation airborne precautions
Critical care module
Hand hygiene, sharps safety, injection safety, personal protection equipment, etc.
Ventilator/respiratory therapy tracer
Spinal injection practices
Invasive procedure module
Infection control in the operating room
Hydrotherapy equipment
Infection control tool
Infection control questions to ask
Questions for employee health nurse in worksheet three
Questions for director of education in worksheet one

Who will Benefit

Infection control nurses or coordinators (Infection control professionals, now called infection preventionist by APIC and CMS), Chief nursing officers, Chief operating officers, Chief medical officers, Nurse educators, Hospital epidemiologists, Infection control committee, All nurses and nurse managers, PI directors, Joint commission coordinators, All nursing supervisors and department directors, Anesthesiologists and CRNAs, Chief medical officers and physicians, Risk managers, Senior leadership, Pharmacists, Board members, Lab directors, Patient safety officers, Compliance officers, Dieticians, Physicians and chief medical officers, Maintenance director and staff, Housekeeping (Environmental Services)OR manager And OR staff All department directors, Anyone with direct patient care, Anyone interested or responsible for infection control

Seminar Summary:

The Centers for Medicare and Medicaid Services (CMS) has finalized the surveyor worksheet for assessing compliance with the infection control Conditions of Participation (CoPs). The worksheets are used by State and Federal surveyors when assessing compliance with the infection control standards. Infection control is hit hard during the survey and every hospital should have a working familiarity with this important document. This is the first time CMS has ever had tracers. Hospitals should develop tracer tools to match this worksheet. Accreditation organizations may also ask similar questions since all four must apply for deemed status from CMS. (see full course description)

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