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06/25/2026

Survey Tip of the Week: Infection Control Training

One of the most common reasons facilities are cited under Infection Control Training F-tag 945 is the failure to ensure all staff receive the required infection prevention and control training. The Long-Term Care Survey Process instructs surveyors to review employee records to verify staff participation in infection prevention and control training.

The infection control training must, at a minimum, include the following areas:

  • The facility’s surveillance system designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;
  • When and to whom possible incidents of communicable disease or infections in the facility should be reported;
  • How and when to use standard precautions, including proper hand hygiene practices and environmental cleaning and disinfection practices;
  • How and when to use transmission-based precautions for a resident, including but not limited to, the type and its duration of use depending upon the infectious agent or organism involved;
  • Occupational health policies, including the circumstances under which the facility must enforce work restrictions and when to self-report illness or exposures to potentially infectious materials (See 483.80(a)(2)(v)); and
  • Proper infection prevention and control practices when performing resident care activities as it pertains to particular staff roles, responsibilities, and situations.

If there is a concern about infection prevention and control practices or healthcare-associated infections in the facility (F880), surveyors are instructed to interview staff and review training records to determine the following:

  • Did staff observations or did interviews with residents and/or resident representatives indicate a training need? Did staff report not receiving training about the concern identified by the surveyor?
  • What process does the facility have to encourage staff to express concerns and request training in challenging situations? Does the facility respond to staff’s concerns and requests for training?
  • Review the training coursework to determine if the content meets professional standards/guidelines and covers facility policy and procedures for infection prevention and control.
  • Does the facility implement the training program and ensure staff are instructed to meet the requirements of §483.80(a)(2), Infection Control, F880?
  • Verify that the facility has a mandatory requirement that all facility staff participate in infection prevention and control training, with a process in place to track such participation.

The State Operations Manual Appendix PP notes that training should support current scope and standards of practice through curricula which detail learning objectives, performance standards, evaluation criteria, and addresses potential risks to residents, staff, and volunteers if procedures are not followed. There should be a process in place to track staff participation in and understanding of the required training.

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