The CMS Hospital Infection Prevention and Control and Antibiotic Stewardship Program - CMS Compliance Requireme

Laura A. Dixon
Recording Webinar Available @All Days
Recorded Webinar


A hospital must have an active infection control program to track, prevent, and control infectious diseases, including Healthcare-Associated Infections, or HAIs. Additionally, the hospital must have a program for optimizing antibiotic use through stewardship. This program will discuss CMS's changes to the infection control standards in 2019 and the interpretive guidelines developed in July 2022.

The program will cover what a hospital must have in place to comply with the regulation, including qualifications of the infection preventionist, the existence of a hospital-wide antibiotic stewardship program, and following nationally recognized infection control standards.

Though no longer utilized by CMS during a survey, the Infection Control Worksheet will be mentioned. It is an excellent tool to prepare a facility for a study because CMS incorporated the areas covered in the worksheet into the standards. 

This webinar will cover the CDC vaccine storage, handling toolkit, and the procedures for cleaning and disinfecting reusable medical devices. The Joint Commission standards on the Antibiotic Stewardship Program (ASP) will be discussed.

Learning Objectives:-

  • Recall the standard and new interpretive guidelines for infection prevention and control.
  • Relate critical requirements for an infection prevention and control program.
  • Identify the requirements for infection prevention and Antibiotic Stewardship lead.
  • Describe what CMS requires for safe injection practices and sharps safety
  • Discuss that CMS has a final infection control worksheet


  • Introduction and important resources
  • New rules 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 infection prevention guidelines
  • CDC Vaccine Storage memo
  • CDC Cleaning reusable devices
  • Infection Control deficiencies
  • CMS Conditions of Participation
  • What an infection prevention program must have and show
  • Infection prevention identified and qualified
  • Leadership involvement
  • ASP program leader's 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
  • 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 tools
  • Appendix and Resources

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
  • 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 lead
  • Anyone with direct patient care
  • Anyone interested or responsible for infection control

Training Options

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