Is an Annual Review of Your Infection Prevention and Control Program Required?

By Sherry Thomas, BS, RN, QCP, IPCO, Clinical Consultant

One of the most common questions we receive from skilled nursing and long-term care organizations is: "Do we have to complete an annual review of our Infection Prevention and Control Program (IPCP)?"

The short answer is yes.

Under F880, facilities are required to conduct an annual review of their Infection Prevention and Control Program. This systematic evaluation is not only an expectation of CMS but also aligns with accreditation standards and infection prevention and control best practices across healthcare settings.

Why the Infection Prevention Annual Review Matters

The annual IPCP review is much more than a regulatory requirement. It provides an opportunity to step back, assess your program's effectiveness, and identify areas for improvement.

A thorough review helps facilities:

• Evaluate infection prevention risks, resources, and operational needs.

• Identify priorities for the upcoming year.

• Develop mitigation strategies to address emerging concerns.

• Establish performance improvement initiatives.

• Demonstrate compliance with CMS regulations and accreditation requirements.

Think of the review as a roadmap that helps guide infection prevention efforts throughout the year.

Is There a Required Template?

No.

CMS does not require facilities to use a specific template or format when completing the review. Each organization can develop a process and documentation approach that best fits its unique resident population, services, risks, and operational structure.

The key is ensuring the review is comprehensive, documented, and meaningful.

Key Considerations for Your Annual IPCP Review

1. Make It a Team Effort

The Infection Prevention team should conduct the review at least annually. Once completed, the findings should be presented to and approved by the QAPI Committee.

Facilities should also ensure the governing body is informed and involved to the extent necessary during the review process.

2. Focus on Analysis, Not Just Documentation

The review should be viewed as an ongoing process rather than a simple checklist exercise.

Before presenting findings to the QAPI Committee, take time to analyze trends, identify gaps, and determine opportunities for improvement. The goal is to understand what the data is telling you and how your program can become more effective.

3. Consider Emerging Infectious Threats

Infection prevention is constantly evolving. Your review should evaluate not only current risks but also emerging infectious diseases and public health concerns that could impact your residents and staff.

Facilities should ensure their IPCP aligns with their Facility Assessment. In many ways, the Facility Assessment should drive the scope of the infection prevention program by helping determine the resources, staffing, training, and preparedness measures necessary for both routine operations and emergency situations.

Common Areas to Evaluate During the Review

While every facility's process will differ, many organizations evaluate:

• Infection surveillance data and trends

• Outbreak response activities

• Employee health programs

• Hand hygiene compliance

• Isolation and transmission-based precaution practices

• Environmental cleaning and disinfection processes

• Antibiotic stewardship efforts

• Infection prevention education and training

• Emergency preparedness related to infectious diseases

  
  

Reviewing these areas can help identify strengths, gaps, and opportunities for improvement.

Turning Compliance Into Continuous Improvement

The annual Infection Prevention and Control Program review is more than a requirement, it is an opportunity to strengthen resident safety, improve outcomes, and proactively prepare for future challenges.

Facilities that take a thoughtful, data-driven approach to their IPCP review are better positioned to identify risks early, implement meaningful improvements, and demonstrate their commitment to quality care.

For a deeper dive into CMS expectations related to infection prevention and control, review the CMS State Operations Manual, Appendix PP – Guidance to Surveyors for Long-Term Care Facilities, which includes detailed guidance for F880 Infection Prevention and Control.

Need Support?

Whether you're preparing for your annual IPCP review, strengthening your infection prevention program, or looking for guidance on regulatory compliance, Engage Consulting can help. Our team works alongside long-term care organizations to identify opportunities for improvement, navigate regulatory expectations, and build sustainable processes that support resident safety and quality outcomes.

Contact Engage Consulting today to learn how we can support your infection prevention, quality, and compliance initiatives.