Infection Preventionist Training: Now or Later?

There is a good argument for training NOW (and possibly a refresher later!). The requirements for the infection preventionist are set to take place with Phase 3 of the CMS Requirements of Participation.

F882 Infection preventionist outlines requirements effective beginning November 28, 2019:

• Designation of at least one individual responsible for the facility’s infection prevention and control program as the infection preventionist(s).

• The infection preventionist must have their primary professional training in:

• Nursing

• Medical Technology

• Microbiology

• Epidemiology and

• Another Related Field

• The infection preventionist must be qualified by:

• Education

• Training

• Experience or

• Certification

• The infection preventionist must work at least part-time at the facility.

• The infection preventionist must have completed specialized training in infection prevention and control.

• Participation in the quality assessment and assurance committee.[1]


Without a comprehensive training NOW for the infection preventionist (or whoever is currently overseeing the infection prevention and control program), who is ensuring that the following current requirements are in compliance: Infection Control (F880), Antibiotic Stewardship (F881), F883 Influenza and Pneumococcal Immunizations and Incontinence (F690) in relation to prevention of urinary tract infections?

Here are just a few key questions (for starters) of the regulatory requirements in place today to consider when weighing the pros and cons of training your infection preventionist:

• Are your policies and procedures evidence-based and do they include all components of F880?

• Are you confident you have a solid system of surveillance to identify possible communicable diseases or infections before they can spread in the facility?

• Have you seen residents on transmission-based precautions and the interdisciplinary team that are not all on the same page on how to handle personal protective equipment, directions or questions by visitors?

• Have you updated your hand hygiene policy and procedure to meet current CMS and CDC recommendations?

• Does your infection preventionist have the tools and resources to be an informed participant in conducting the annual review of your infection prevention and control program, and is the program updated as necessary?

• Who is educating your prescribing practitioners and nurses on your antibiotic stewardship protocols in the facility? What documentation do you have to substantiate this education?

• Is your staff proficient in understanding when to use transmission-based precautions, what to do and how to ensure the least restrictive environment for the individual circumstance?

• Are you confident in your occupational health program management?

• Who is providing employee education and verification of competency for the infection prevention and control program?

• Do you have a solid program for medical device safety, including point-of-care testing?

• Who is recording and managing infection prevention and control program incidents and ensuring corrective action?

• Is there a solid system for practices on handling, storing, processing and transporting linens?

• Do you have a water management program to reduce the growth and spread of Legionella in your facility?

• Are you confident with oversight of your facility vaccination/immunization program?


Once again, these are just a few items that point out the significant need for an infection preventionist who has adequate training to implement, oversee and manage the infection prevention and control program now for quality and regulatory compliance. Infection control still remains at the top of the compliance meter across the country; therefore, why wait to have your infection preventionist trained? You can always refresh your knowledge and skills later!

[1] CMS State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17).


Sue Lagrange,
Director of Education,
Pathway Health