Countdown to Phase 3 - Skilled Nursing Infection Preventionist

Beginning on November 28, 2019, surveyors will use the requirements detailed in 42 C.F.R. Section 483.80 of the Code of Federal Regulations Requirements for States and Long-Term Care Facilities (“Final Regulations”) to determine whether a skilled nursing facility (“Facility”) has an infection preventionist on staff who is a primary professional trained in nursing, medical technology, microbiology, epidemiology or other related field.

This is another article in a series discussing the complete overhaul of Part 483 to Title 42 Final Regulations by the Centers for Medicare & Medicaid Services (“CMS”). To view other articles in this series, click here.

Background – Infection Control – Sec. 483.80

Section 483.80 of the Final Regulations requires facilities to establish and maintain an infection prevention and control program (“IPCP”) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP must include an antibiotic stewardship program that addresses antibiotic use protocols and systems for monitoring antibiotic use. The Final Regulations detail the elements that must be included in an IPCP. These elements include, but are not limited to:

A system for preventing, identifying, reporting, investigating and controlling infections and communicable disease. This includes staff, visitors, volunteers and others performing contracted services to the facility;
Written standards, policies and procedures; and
When and how isolation will be utilized for a resident.

The IPCP must have a system for reporting incidents and corrective action taken by the Facility in response to the incident(s). Section 483.80(f) requires each Facility to conduct an annual review of its IPCP and update its program as necessary.

For almost two years, the Final Regulations have called for the IPCP to be linked to Facility’s facility assessment in Section 483.70(e) and for the Facility’s antibiotic stewardship program to be operational.

Infection Preventionist

The Final Regulations require Facilities to appoint an infection preventionist (“IP”) who is responsible for the Facility’s IPCP. The IP’s participation in the Quality Assessment & Assurance (“QAA”) is also required.

In addition, the IP:

Must have professional training in nursing, microbiology, medical technology, epidemiology or a related field;
Must be qualified by education, training, experience or certification;
Must work at least part-time at the facility; and
Must have completed specialized training in infection prevention and control.

State Operations Guidance to Surveyors

CMS has not issued guidance on how surveyors will interpret and cite the IP requirement.

Absent guidance from CMS, surveyors will likely ask to see the Facility’s documents regarding the IP employee, the IP’s qualifications and evidence of the IP’s role in the Facility’s QAA.

Proposed Regulations

On July 18, 2019, CMS published proposed revisions (“Proposed Rule”) to the Final Regulations. CMS stated that it identified a number of existing skilled nursing facility requirements that could reduce unnecessary burdens on Facilities if they were simplified or eliminated. As of the date of this article, CMS has not finalized the Proposed Rule by publishing final regulations.

The Proposed Rule proposes to remove the requirement that the IP work at the Facility “part-time” or have frequent contact with the IPCP staff at the Facility. The Proposed Rule instead requires that the facility must ensure that the IP has sufficient time at the Facility to meet the objectives of its IPCP.

Implementation Time Frame

Beginning on November 28, 2019, surveyors will use the requirements detailed in Section 483.80 to determine whether a Facility has a qualified IP and fulfills the requirements in the Final Regulations.

Action Items

Facilities should:

Designate one or more individuals as the IP;
Confirm that the IPs at the Facility meet the requirements of Section 483.80;
Confirm that the IPs at the Facility have completed the appropriate specialized training; and
Implement a policy and procedure on how the IPs are included in the QAA and issue reports to the QAA.

Policies and Procedures Available

Hall Render has developed policies and procedures to assist skilled nursing facilities in achieving compliance with Section 483.80 and the Final Regulations. For more information about those policies and procedures, about this topic, or if you would like assistance with the IP requirement in the Final Regulations, please contact: