Two months into Phase 3 of the Center for Medicare & Medicaid Services’ latest Medicare rules of participation provisions, nursing homes are well-versed in stricter infection control rules around antibiotic prescribing. With those new rules comes a new required role, an infection preventionist, that will require challenging staff mandates. Experts offer sage advice for navigating the changes ahead.

1. Self-educate thoroughly on the rules of participation provisions.

Be aware that prescribing physicians’ compliance from a nursing home perspective is problematic, “because emergency departments and doctor’s offices frequently prescribe antibiotics outside of the provisions,” says Ellen Thompson, BSN, RN, CWS, FACCWS, wound and product specialist for Gentell.

As a result, staff need to anticipate facilitywide compliance issues. 

“Each nurse must be compliant to achieve success,” adds Thompson. The charge nurse, therefore, “must be very comfortable in their assessment skills and judgement in order to relay needed information to the prescribing physician,” or risk hesitating to advocate for decreased usage of unnecessary antibiotics.

The most challenging provision: all facilities not only will need to have an infection control process in place, but also a dedicated infection preventionist on staff who works at least part time and meets the necessary education and training qualifications outlined by CMS, says Benjamin Oberle, healthcare and education marketing specialist for 3M.

Because of this new demand, providers should be prepared for workforce strains.

Janine Finck-Boyle, vice president of regulatory affairs for LeadingAge, asserts that many facilities already facing high turnover and recruitment issues could be severely stressed filling this new position requiring “incredibly dynamic expertise.”

Those facilities able to invest in the needed education and training could recruit an existing nurse (ideally two for backup) from the ranks to fill the IP role, says Boyle, noting that CMS does provide free online IP training.

2. Like most massive regulations, long-term care workers have learned to adapt even when compliance issues are in flux or being hammered out. Absent the pending “interpretive guidance, flying blind is the norm.

That doesn’t come with exemptions, however. “CMS will be surveying on all requirements, and providers will not get a free pass just because there is no guidance,” Boyle adds. 

Thompson advises staff to exploit the delay by getting a solid IP program in place — sooner rather than later.

“Develop policies and procedures that will guide your staff in realistically achieving compliance,” she says. “Determine how you would like to accomplish those goals and make them measurable and achievable.”

Amanda Thornton, RN, MSN, CIC, VA-BC, clinical science liaison for PDI, strongly urges facilities to use the time now to implement staff training and education, as well as filling in program gaps and developing policies and procedures.

Thornton also advises providers to nurture strong working relationships with state and local health departments, and tap vendor resources, for assistance in the IP implementation.

Now is the time to also assess the facility’s existing infection control and prevention program, Thornton adds. Great resources for this are available through the CDC at

“Nursing homes should start documenting their protocols for infection prevention and what staff members currently do to reduce the chain of infection,” Oberle adds. This will help inform where they are today so that they can identify and remedy critical gaps in the process.”

3. Finally, prioritize the work ahead.

Formulating and implementing a plan of action and working together collectively to reduce antibiotic usage rates and infection rates is the place to start,” says Thompson. “If facilities have not developed an infection prevention program, that should be top priority,” warns Thompson. “If they have an IP program in place, stringent monitoring of that program and its effectiveness is critical.”

Of equal importance is staff training, Boyle adds. This includes a requirement that the infection preventionist begin providing regular updates to the Quality Assessment and Assurance committee. And providers must be diligent about maintaining documentation to provide evidence of compliance.

Thornton advises facilities to give special attention to their antibiotic stewardship programs, as well as ensuring outbreak-related state and local compliance requirements are being met.