Ftag of the Week – F945 Infection Control Training

This week on the CMSCG Blog, our “Ftag of the Week” is one of the training regulations that lacked guidance until the draft revisions to State Operations Manual Appendix PP were published in June. Given the non-stop emphasis on everything related to infection prevention and control throughout the COVID-19 PHE, it’s unlikely nursing homes haven’t been providing staff with infection control training, but now we know the minimum areas that need to be addressed in your training program.

Who Needs this Training?

Providers are expected to develop and implement an infection control training program for all facility staff, staff working under contract and volunteers, consistent with their roles. The training is expected to be a formalized program and participation should be tracked.

Minimum Training Areas

The following areas must be included in the training program:

  • Facility surveillance to identify possible communicable disease or infections before they can spread
  • When required, incidents of communicable disease/infection in the facility should be reported, and to whom
  • Precautions
    • Standard
    • Transmission-based
  • Occupational health policies, including those related to staff self-reporting of illness or exposure to potentially infectious materials and enforcement of work restrictions

Training Program Revisions

The program is expected to be a “living” document with content that may need to be revised based on several factors. These include changes to:

  • The Facility Assessment
  • The resident population
  • The physical environment
  • National infection prevention and control standards
  • Community risk levels
  • Staff turnover

On Survey

We all know infection control observations have been a key area where surveyors have been focusing. While issues identified during observations can result in a citation at F880 or one of the other Infection Control regulatory group F-tags, you could also be cited at F945. A citation at F945 may be warranted if surveyors observe staff with poor infection control practices that could indicate staff did not receive training about the identified concern. A surveyor could also identify an issue with training through resident/representative interviews which indicate that staff have not received appropriate infection control training. Surveyors are additionally guided to review the facility’s training program materials to determine if the content meets professional standards and addresses the facility’s Infection Control policies and procedures.

CMSCG Survey Tip

Now’s the time to review your training materials to ensure they are current and that there is documentation in place regarding staff training. Given that F880 Infection Prevention and Control is the most frequently cited deficiency across the United States currently, it increases the likelihood that surveyors will check to see how staff are trained once the new guidance is effective in October 2022. Don’t forget the need to add education on Monkeypox to your comprehensive Infection Prevention and Control Program.

About CMS Compliance Group, Inc.

CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm with extensive experience servicing post-acute and long term care facilities and agencies. With the idea of continuous quality improvement in mind, CMS Compliance Group’s interdisciplinary team provides a unique approach to client service, ensuring that all departments can achieve and maintain compliance while improving quality of care. Our consultants provide proactive and reactionary compliance consulting services to clients across the country and have an established reputation for rapidly addressing and successfully resolving the most serious issues that occur in nursing homes, assisted living facilities, home health agencies and other post-acute providers. To discuss our consulting services, including assistance with preparing for the updated regulatory requirements, please call 631.692.4422 or fill out a contact form and someone will be in touch.

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