The CMS Hospital Interpretive Guidelines on Infection Control and Antibiotic Stewardship Program

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
120 minutes
Product Description

Learn About the CMS Interpretive Guidelines on Infection Control, Safe Injection Practices and Antibiotic Stewardship Program Updates

Infection control is a very important issue in today’s healthcare environment and should be a top priority for hospitals. It can cost hospitals money if it is not done right! The CDC estimates that there are about 1.7 million healthcare associated deaths in America every year and it is estimated that healthcare acquired infections (HAIs) incur nearly $20 billion in excess healthcare costs each year. This is also why HAIs are a top priority for the U.S. Department of Health and Human Services.

Hospitals that receive Medicare reimbursement have to comply with the CMS interpretive guidelines on infection control. CMS has hospital acquired conditions (HACS) in which there is no additional payment to hospitals for certain infections. Several of the 29 Never Events are infection control issues and many insurers are trying to put into hospital contracts that the hospital cannot bill for these. Surveyors can cite hospitals for being out of compliance with the hospital conditions of participation (CoPs). The Hospital-Acquired Condition (HAC) Reduction Program is in effect and 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 their CMS payments reduced by 1%. Hospitals need to have a good infection control practices in place or face denial of reimbursement. Therefore, it is important that your infection preventionist and staff be up to date on this essential information.

This session by expert speaker Sue Dill will cover the current CMS infection control standards in detail. Sue will also cover the TJC antibiotic stewardship program requirements and the CMS proposed infection control standards which also includes a requirement for an antibiotic stewardship program. This session will include the CDC Core elements for hospitals and outpatient departments regarding their antibiotic stewardship program. It will also include some significant proposed changes to the infection control standard from the Hospital Improvement Act. Sue will discuss the CDC and FDA update review procedure for cleaning, disinfecting, and sterilizing reusable medical devices and the CDC vaccine storage and handling toolkit.

She will also be discussing the common deficiencies in infection control. The number of infection control deficiencies has gone up significantly and this should be on the radar screen of every hospital. She will provide you with tips to prevent getting a deficiency. Both CMS and TJC have issued memos on steam sterilization and flash sterilization (now called immediate use steam sterilization) which will be discussed along with memos on cleaning of scopes. Hospitals have to use the CDC system to report central line infections for ICUs. Safe injection practices are important and hospitals should have a policy and procedure on this. This session will include the ten CDC safe injection practices. Sue will also discuss the CMS issued survey memos on safe injection practices, infection control breeches, two on humidity, three on EBOLA, one on CRE and ERCPs and insulin pen memos. The session will include an important memo about four unsafe injection practices.  These are four of the ten CDC safe injection practice requirements.

CMS requires hospitals to follow standards of care. This session will discuss ISMP published guidelines on IV push drugs for adults, mentioned by CMS in the CoPs. Sue will cover the CDC guidelines on vaccine handling and storage. You will get additional resources including the proposed changes to the hospital infection control worksheet.

Session Highlights

  • Understand policies and procedures required by CMS in the area of infection control
  • Understand the Joint Commission’s antibiotic stewardship program requirements
  • Discuss that CMS requires that the national standards of care and practice must be followed such as those from the CDC, SHEA, APIC, OSHA, and AORN
  • Understand that all glucose meters should be cleaned after each use
  • Understand CMS requirement for mandatory education in infection control
  • Learn that a clean needle and syringe should be used each time under the safe injection practices memo issued by CMS

Session Agenda

  • Introduction of the CMS infection control standards
  • Overview of the conditions of participation
  • Keeping up with the changes
  • Proposed CMS infection control changes
  • National action plan to prevent healthcare-associated infections
  • Active antibiotic stewardship program
  • Checklist for core elements of hospital antibiotic stewardship programs
  • Antibiotic use in the United States: Progress and opportunities
  • Antimicrobial stewardship toolkits
  • Practice guidelines for implementing antimicrobial stewardship
  • CMS deficiency reports on infection control
  • List of CMS deficiencies noticed in the medical facility
  • CMS survey memos on infection control
  • Water management system
  • CMS memo on safe injection practices
  • Review procedures for cleaning, disinfecting and sterilizing reusable medical devices
  • Guidelines for disinfection and sterilization in healthcare facilities
  • Vaccine storage and handling toolkit
  • ISMP guidelines on IV push medication
  • CMS hospital worksheet on infection control


Who Should Attend

  • Infection control nurse or coordinator (infection control professionals, now called infection preventionists by APIC and CMS)
  • Chief nursing officer
  • Chief operating officer
  • Nurse educator
  • Hospital epidemiologists
  • Infection control committee
  • Nurses and nurse managers
  • PI director
  • Joint Commission coordinator
  • All nursing supervisors and department directors
  • Anesthesiologist and CRNAs
  • Chief medical officers and physicians
  • Risk manager
  • Senior leadership
  • Pharmacists
  • Board members
  • Lab director
  • Patient safety officer
  • Compliance officer
  • Dietician
  • Maintenance director and staff
  • Housekeeping (environmental services)
  • OR manager and OR staff
  • Anesthesia staff
  • Anyone interested or responsible for infection cont

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of...   More Info
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