The CMS Hospital Infection Control and Antibiotic Stewardship Program: CMS Compliance Requirements 2022

Laura A. Dixon
From: May 27, 2022 - To: Dec 31, 2022
Recorded Webinar


This program will discuss the many changes to the infection control standards that went into effect in November 2019, including a new requirement to have an antibiotic stewardship program.

The program will cover in-depth the Infection Control Worksheet from CMS. Though no longer utilized by CMS, it is an excellent tool to prepare a facility for a survey.  The conditions of participation and standards in the manual will be addressed using the worksheet. CMS incorporated the areas covered in the worksheet into the standards. 

Other requirements of the recent changes include the infection preventionist needs to be appointed by the board after approval by nursing leadership and Medical Executive Committee. Hospitals must have a hospital-wide antibiotic stewardship program and follow nationally recognized infection control standards.

This webinar will cover the CDC vaccine storage and handling toolkit and the CDC procedures for cleaning and disinfecting reusable medical devices.

Finally, infection control issues related to COVID-19 will be discussed. This includes several memos from CMS including the targeted infection control surveys and self-assessment. The CDC also has many resources and recommendations on COVID-19 that will be covered.

Learning Objectives:-

  • 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


  • Introduction and important resources
  • The new rule and overall changes
  • Joint Commission ASP requirements
  • CDC Infection Control resources for professionals and training
  • CMS memos and CDC guidance
  • Legionellae and TJC and CMS information
  • ISMP IV Push guidelines
  • CDC Vaccine storage memo
  • CDC Cleaning reusable devices
  • Infection Control deficiencies
  • CMS Conditions of Participation
  • What the program must have and show
  • Infection preventionist identified and qualified
  • Leadership involvement
  • ASP program leader responsibilities
  • Unified and integrated programs
  • CMS Worksheets – overall
  • Infection control programs and resources
  • Hospital QAPI and infection prevention
  • Systems to prevent MDRO and correct antibiotic usage
  • Infection prevention systems and training
  • Hand hygiene processes
  • Injection practices and sharps safety
  • Personal Protective Equipment
  • Environmental cleaning and disinfection
  • Reprocessing noncritical items
  • Reprocessing semi-critical items
  • Reprocessing reusable critical equipment
  • Immediate use sterilization
  • Single-use devices
  • Urinary catheter tracer
  • Central venous catheter tracer
  • Isolation droplet precautions
  • Isolation airborne precautions
  • Ventilator/respiratory therapy tracer
  • Spinal injection practices
  • Point of care devices (blood glucose monitors and INR monitors)
  • Isolation contact precautions
  • Invasive procedure module
  • Infection control in the Operating Room
  • Infection control and COVID-19
  • Infection control tools

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
  • Chief Medical Officer
  • Nurse educator
  • Hospital epidemiologists
  • Infection control committee
  • All 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
  • All department directors
  • Antibiotic stewardship members and head
  • Anyone with direct patient care
  • Anyone interested or responsible for infection control.

Training Options

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