Closeup image of gloved hands spraying surface with disinfectant for infection control

While nursing homes have had six years to prepare for new infection preventionist guidance, the Centers for Medicare & Medicaid Services revealed last week they will not necessarily need to appoint someone to the role full-time.

The move could be a nod to the current labor shortage in skilled nursing  — and the fact that 40% of existing IPs are approaching retirement age  — but the compromise leaves some observers worried that nursing homes will remain unprepared for the next major infectious disease outbreak.

In a memo to state surveyors, CMS said it will require nursing homes to have an IP with “specialized training onsite at least part-time to effectively oversee the facility’s infection prevention and control program.”

Deb Burdsall, PhD, CIC, a consultant with the Association for Professionals in Infection Control and Epidemiology and the Illinois Department of Health, called it “understandable but disappointing that CMS has chosen not to follow CDC’s guidance for the hours required to do an adequate job as infection preventionist.” 

Deborah Burdsall

She said high COVID mortality rates and the increasing prevalence of serious multi-drug resistant organisms in long term care demonstrate a need for more dedicated attention to infection control. Burdsall, who spent decades working in long-term care settings, urged providers to look closely at the new CMS language carefully.

“While they don’t require a specific number of hours, surveyors will be looking for fully implemented infection prevention and control programs,” she told McKnight’s Long-Term Care News last week. “Many care communities need significant work to develop a complete infection prevention and control program, including complete vaccination programs, respiratory protection programs, water management, infection prevention training, competency,  monitoring, surveillance and employee health.”

More details finally emerge

Specifics on the IP position were one of the biggest missing parts of Phase 3 guidance governing the Medicare program’s Requirements of Participation. In 2016, providers were warned that an IP requirement was on the way. But just weeks before the provision was to go into effect in 2019, CMS leaders announced they wouldn’t push out guidance — and would limit enforcement — until the second quarter of 2020. Then COVID hit.

The critical nature of a dedicated infection-focused employee became all the more clear during the pandemic, when many facilities had to turn to hospital partners or local health departments for lack of their own full-time infection preventionist. In many settings, nurses in that role were also called back to the floor for patient care. Others had positions designed to be split among multiple facilities —  a strategy that became more challenging as providers looked to limit COVID transmission.

Some observers, including Burdsall, had hoped the pandemic would move CMS to make full-time infection control personnel standard for nursing homes. Instead, the agency said factors guiding the IP’s hours should include census; resident characteristics such as the presence of respiratory care units, memory care or other services for complex care; and outbreaks or seasonal infections. The agency said the IP “must have the time necessary” to properly assess, develop, implement, monitor, and manage the infection prevention and control plan for the facility, address training requirements, and participate in required quality committees. 

It also laid out that the IP must be professionally-trained in nursing, medical technology, microbiology, epidemiology, or other related fields and hold requisite degrees or certifications. It also offers possible training routes that would meet the agency’s call for specialized education.

The guidance also provides important clarity for nursing homes that have relied on corporate infection preventionists, noting that the IP “must physically work onsite in the facility.”

“He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility,” the guidance states.

Competency and resources are keys

In a call with LeadingAge members just hours after the guidance was released on Wednesday, Nursing Home Quality and Policy Director Jodi Eyigor noted that it encourages providers to “implement and integrate the lessons learned from COVID, with additional emphasis on communicable diseases, standard precautions and transmissions-based precautions.” That includes details on how to protect residents from multidrug resistant organisms and legionella.

“With your infection preventionists, it’s not just about the qualifications. That’s what we know from the requirements,” Eyigor said. “But the guidance goes into more about competency and making sure that the infection preventionist has the resources to act effectively, that you’re using your facility assessment to determine if the IP’s only role should be infection prevention and control programs, making sure that based on your facility assessment, the infection preventionist has the training and specialized training and addtl competencies that are needed to care for your specific resident population.”

Increasingly, evidence is showing that IPs can improve quality of care and protect both residents and staff in nursing homes. A June study from California, which already requires full-time IPs in nursing homes, found that training and continuous audits made possible by a full-time IP pushed compliance with hand hygiene and other prevention practices to near-perfect levels.

But a recent survey out of the University of Michigan also shows that nursing home IPs have seen their infection prevention workloads increase — thanks in no small part to COVID monitoring and reporting duties — while their other duties remain just as time-consuming.

Burdsall remains hopeful that nursing homes will weigh the new guidance and deem a full-time IP a worthwhile investment so that they don’t have to continue to juggle. 

“Infection preventionists are members of an evolving and developing profession,” she said. “In the same way that MDS/RAI coordinators, rehab and restorative nurses, and directors of nursing need time to do their very important job managing the program, IPs need time to develop and maintain functioning infection prevention and control programs.”