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Infection Control: Long-term Care Survey and Regulatory Implications

10 May 21

Infection control is a concept familiar to the long-term care industry for the past decade or longer. It will continue to be a focus for surveyors as the industry reflects on lessons learned during the COVID-19 pandemic and how those lessons will prepare facilities for the future.


Infection control is not new to the long-term care industry, but providers are facing new challenges as they work to protect residents and staff. In February 2021, we gathered three leading industry experts to discuss how COVID-19 contributed to the ‘unmasking’ of infection control protocols within long-term care facilities. These experts offered some valuable tips on how long-term care facilities can mitigate their infection control risks.


An overwhelming theme by all three experts was the importance of education. However, they agreed improving infection control practices needs to extend beyond education by tying it to competencies. Tying competencies to education must be developed with the right formula so let’s break this down and help you understand what this may look like for your facility.

First, seek out a full-time infection preventionist (IP) if your facility does not already have a qualified individual in this role. Dr. Gifford, MD, MPH and Chief Medical Officer at the American Health Care Association, advised that an IP is instrumental in driving infection control training. Ideally, an IP is extremely knowledgeable about F-880 regulations and can help facilities develop protocols to reduce or avoid any infection control related citations. A May 1, 2021 article in McKnight’s also emphasized the importance of a well-trained IP (Marselas, 2021). This article supports Dr. Gifford’s recommendation that an IP should lead QAPI efforts within their facility.

You may be thinking…well, my facility has an IP that facilitates quality training, but we were still issued an infection control citation. This is where competencies need to tie in with training. Linda Shubert, MSN, RN and Director, Clinical Management at Healthcare Academy, stressed that training MUST be tied to competencies. Although each long-term care facility must decide a ‘best fit’ for tracking competencies within their facility, Shubert offered some ideas for getting started.

Competency checklists is a great place to start. These checklists are an efficient way to identify, assess, correct, and document a wide range of skills required for long-term care staff to demonstrate competency. Complementary options to use with a competency checklist include: interviewing staff, observing staff demonstration of standards, and audit, audit, audit! Shubert even cited “Man on the Street” as a helpful way to observe competencies. This exercise involves nursing leaders or educators pretending to be surveyors and asking staff questions typically asked by surveyors. Shubert noted, “it is a great way to understand what staff are doing and why they are doing it.”


Although training combined with competencies is the most effective strategy for mitigating risk of an infection control citation within your facility, a citation may still occur.  Especially since a May 7, 2021 article in Skilled Nursing News indicated the number of surveys nationwide has risen 132% since 2020.  This statistic is proof that facilities need to ensure they have solid and well-documented processes for tying competencies to education.   

Perhaps, you’ve been in a position of receiving the dreaded CMS-2567 or wonder how you would handle receiving this news.  Rebecca Coffin, J.D. and partner at Voigt, Rodè, Boxeth & Coffin, offered some criteria/questions to consider if your facility is issued a CMS-2567.  Please note, this is not legal advice but may be helpful in determining if your facility is in a good position to file an appeal.  Coffin recommends evaluating the following information:

  • The law – ask, “Are we in compliance?”
  • The facts – there are two sides to the story; ask, “Are allegations in 2567 accurate?”
  • Immediate jeopardy – ask, “Does the situation meet the definition of immediate jeopardy?”
  • PR and CMS 5-Star – ask, “How will this impact the public’s view of this facility?
  • Timing and cost – ask, “Is it worth pursuing an appeal?”

Improving infection control protocols within your facility takes time, commitment, and effort by the entire interdisciplinary team.  Ensure you have a well-trained infection preventionist who is dedicated to implementing, monitoring, and documenting evidence-based education combined with tracking competencies


Not sure where to start with competencies?  Let us help you assess, remediate, and document staff competency with our Healthcare Academy’s digital competency tool eCompetencies®.   Learn more here or contact us to speak to an HCA team member. 


Marselas, K. (2021, May 1). Flying blind with infection control. Retrieved May 7, 2021 from https://www.mcknights.com/print-news/flying-blind-with-infection-control/

Skilled Nursing News. (2021, May 7). Skilled nursing facility surveys skyrocket during pandemic.  Retrieved May 10, 2021 from https://skillednursingnews.com/2021/05/skilled-nursing-facility-surveys-skyrocket-during-pandemic/?euid=1329438165&utm_source=snn-newsletter&utm_medium=email&utm_campaign=3025786afd 

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