WEBINAR: CMS Infection Control Worksheet and Proposed Change

If there is one webinar your hospital should listen to this year it would be this one. If a surveyor showed up at your door tomorrow would you be prepared?

The worksheet is used for all validation surveys and certification surveys. This webinar will also discuss the proposed infection control standards. 

Webinar 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 the hand hygiene tracer

Target Audience
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, 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, Anyone with direct patient care and anyone interested or responsible for infection control.

Webinar Topics:
Infection Control Final Worksheet for Hospitals
49 page final hospital infection control worksheet
Proposed changes in 2017 
o Antibiotic stewardship program,
o IP qualified
o Many proposed changes
Infection preventionist identified and qualified
Infection control program and resources
Infection control policies required (many)
Follows national 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
o Antibiotic orders include indications for use
o Prompt for clinicians to review 
o Log of incidents rescinded
o CAUTI, VAP, SSI, MRSA, D-DIFF, CLABSI are identified and new tracers on HAI
o Process to identify present on admission or POA
o HCP competency assessments
o Identify and report and control infections
o MDRO and contact precautions
Module on hand hygiene
Infection prevention systems and training
Injection practices and sharps safety
Environmental cleaning and disinfection
o Disinfectants used correctly
o High touch environmental surfaces
o Reusable noncritical items (BP cuffs, pulse ox probes)
o Single use devices
o Laundry requirements
o Policies and procedures required
Point of care devices (blood glucose monitors and INR monitors)
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
o 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

Sue Dill Calloway, RN, Esq. CPRHM, AD, BA, BSN, MSN, JD, Attorney at Law
President of Patient Safety, Healthcare Consulting and Education Company

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal and risk management issues and writes numerous publications.

Ms. Calloway has given many presentations locally and nationally to nurses, physicians and attorneys on medical and legal issues. She has authored numerous articles and over 1000 articles and 100 books, including the 2009 Joint Commission Leadership Standard (HCPro), Nursing and the Law (PESI, 1986 and 1987), Ohio Nursing Law (West Publishing), Nursing Ethics and the Law (PESI, 1986), Legal Issues in Supervising Nurses (PESI, 1988), Medicine Made Easy (PESI, 1992) and The Law for Nurses Who Supervise/Manage Others (PESI, 1993), Legal Issues in Obstetrics (PESI, 1997) and JC Leadership Standards (HCPro, 2004), and the Compliance Guide to the CMS and the Joint Commission Patient Rights Standards (HCPro, 2005), and the 2009 book on the Joint Commission Leadership Standards (HCPro). She often writes articles called the “CMS Corner” in Briefings on the Joint Commission. Ms Calloway is a 1996 recipient of PESI's Excellence in Education Award.

Nursing CEU Credits: 
Nursing participants: This program has been approved for 2.4 contact hours by the Iowa Board of Nursing Approved Provider Number 339. Completion of offering required prior to awarding certificate.
All other participants: Must attend the entire Webinar. The webinar registrant must also submit a sign-in sheet with names of all attendees to Anasthia Amos (aamos@mhanet.org) to be eligible for MHA Continuing Education credits. 
5/1/2017 9:00 AM - 5/1/2017 11:00 AM
United States


Monday, 01 May 2017

9:00 AM - 11:00 AM
5/1/2017 9:00 AM
5/1/2017 9:00 AM
9:00 AM - 11:00 AM
5/1/2017 9:00 AM
5/1/2017 9:00 AM
9:00 AM - 11:00 AM
5/1/2017 9:00 AM

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