Use CMS regs to bring leaders into program
What to expect from a CMS inspection
Infection preventionists should make sure their administrative leaders are aware in a collegial, non-confrontational way of course that the Centers for Medicare & Medicaid Services (CMS) requires top-level support for infection control programs, advises Connie Steed, RN, BSN, CIC, manager of infection control at the Greenville (SC) Hospital System.
Speaking on compliance issues recently in New Orleans at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC), she emphasized that the current CMS conditions of participation regarding infection prevention includes this unequivocal language:
"The CEO, the medical staff and director of nursing must ensure that the hospital-wide QA program and training programs address problems identified by the ICO [infection control officer] and be responsible for the implementation of successful corrective action plans in affected problem areas."
Using the CMS provision as leverage, Steed got physician and nursing leaders involved in her annual infection control risk assessment, which many IPs do to comply with the Joint Commission. However, such accreditation requirements are ceded to the Joint Commission and other groups by the CMS, whose inspectors may likely ask to review them as well.
"This gave me an opportunity," she said. "It's amazing how your infection prevention process changes when it is not just the infection prevention staff in the room. Your [risk assessment] should not be done by you alone. It should be a multidisciplinary process that includes leadership and key individuals within your organization that impact what you do and impact the quality of care."
As part of that of course, you must identify opportunities and implement interventions to mitigate infection risk, she added. "They want to see a program evaluation and revisions as needed," she said. "I will tell you that for any organizational priorities, goals if you add a service they want to see that you have modified your plan."
In general, CMS inspectors lean toward documentation and policies like infection prevention guidelines from the Centers for Disease Control & Prevention, she noted. "They may just right up front say, we received a complaint on this and we would like to see these policies that you have put in place in your organization and you must provide them," Steed said.
CMS inspections are not necessarily limited in scope, she reminds. "If you have clinics, ambulatory surgery centers, if you have a satellite hospital, CMS is privileged to go into any of those sites," she told APIC attendees. "And they will."
The key program components CMS inspectors typically assess include a sanitary environment and evidence of surveillance for infections. A CMS requirement for a "log" of infections continues to generate confusion, she said.
"A lot of IPs have struggled with this," she said. "Some people really think they want a list of every infection. It doesn't have to be one log. We have figured out what we can do for CMS surveyors. You can show them your MRSA line list, your VRE line list, your other HAI surveillance line lists."
Steed also keeps a regularly updated printout of positive cultures from the lab. And CMS does expect to see a list of communicable disease reports made to the public health department, she added.
"That has caught some people because you have to keep a log somewhere on all of the communicable diseases that you report to public health," she said. "Our lab does most of the reporting to public health, so I have developed a system where lab reports [also come to us]."
Infection preventionists should make sure their administrative leaders are aware in a collegial, non-confrontational way of course that the Centers for Medicare & Medicaid Services (CMS) requires top-level support for infection control programs, advises Connie Steed, RN, BSN, CIC, manager of infection control at the Greenville (SC) Hospital System.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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