New CMS Regulations Late Breaking Update

Key Points Develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program Designate at least one Infection Preventionist (IP)

Dates Phase 1- November 28, 2016 Phase 2- November 28, 2017 Expected to cost $19,000 per facility annually

Phase 1 483.80 Infection control

New wording When and how isolation should be used for a resident, including but not limited to, (A) the type and duration of the isolation depending upon the infectious agent or organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances

Phase 2 Facility Assessment at §483.70(e) Antibiotic stewardship

Facility Assessment 483.70(e) A system for presenting, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing service under a contractual agreement that based on the facility assessment

Resident Population Facility’s capacity and occupancy Care required by the residents considering types of disease, conditions, physical and cognitive disabilities, overall acuity and other pertinent facts Staff competencies to provide resident care Physical environment, equipment, services and other considerations Any ethnic, cultural or religious factors

Facility Resources Building and structures Equipment (medical and non-medical) Services provided (PT, pharmacy, rehabilitation) Personnel Contracts and agreements Health information management All-hazards assessment community-based

Antibiotic stewardship program Antibiotic use protocols System to monitor antibiotic use

Phase 3 Infection Preventionist (IP) IP participation on QAA committee

Infection Preventionist (IP) Designate one or more individuals as the IP IP is responsible for the IPC program Has primary training in nursing, medical technology, microbiology, epidemiology or other related field Be qualified by education, training, experience, or certification Work at least part-time Have completed specialized training in IPC

Other requirements IP must be a member and report on a regular basis Policies on influenza and pneumococcal vaccination Education provided prior to immunization Influenza offered October 1 to March 31 Documentation in the medical record Annual review of IPC program

Infection Prevention and Control Program Written standard, policies, and procedures System of surveillance to identify possible communicable diseases and infections When and whom possible incidents are reported Standard and transmission based precautions When and how isolation is used Type and duration of isolation; least restrictive measure Employee work restrictions Hand hygiene Corrective actions taken