SMQT Infection Prevention and Control 5 — Questions and Answers
Question 1: A surveyor discovers that a facility does not have a designated infection preventionist (IP). Under the revised CMS Requirements of Participation, what is required?
- A facility with fewer than 100 beds is exempt from this requirement
- At least one individual must be designated as the IP and must be qualified through training or experience (Correct answer)
- The medical director automatically serves as the IP
- The requirement only applies to facilities with active outbreak investigations
Correct answer: At least one individual must be designated as the IP and must be qualified through training or experience
CMS requires every long-term care facility to designate at least one qualified infection preventionist regardless of facility size.
Question 2: When evaluating a facility's laundry handling practices, which observation would be MOST concerning from an infection control standpoint?
- Clean and soiled laundry transported in separate carts
- Staff wearing gloves when handling soiled linens
- Soiled and clean laundry stored in the same room without separation (Correct answer)
- Laundry washed at temperatures above 160°F
Correct answer: Soiled and clean laundry stored in the same room without separation
Storing soiled and clean laundry in the same space creates cross-contamination risk; physical or temporal separation is required.
Question 3: Which type of personal protective equipment (PPE) is required for a healthcare worker performing bronchoscopy or suctioning on a resident with known or suspected influenza?
- Gloves and gown only
- Surgical mask, gown, and gloves
- N95 respirator, eye protection, gown, and gloves (Correct answer)
- Standard precautions with no additional PPE needed
Correct answer: N95 respirator, eye protection, gown, and gloves
Aerosol-generating procedures with influenza patients require airborne-level respiratory protection (N95), eye protection, gown, and gloves.
Question 4: A surveyor assesses a facility's sharps disposal practices. Which observation indicates FULL compliance?
- Sharps containers are placed in a central hallway location only
- Needles are recapped after use before disposal to prevent needlesticks
- Sharps containers are located at the point of care and replaced when three-quarters full (Correct answer)
- Used syringes are placed in regular waste bins lined with red biohazard bags
Correct answer: Sharps containers are located at the point of care and replaced when three-quarters full
Sharps containers must be at point of care for immediate disposal and replaced before reaching capacity to prevent overfilling and injury.
Question 5: A facility experienced a bloodborne pathogen exposure incident involving a staff member. Which action is REQUIRED under OSHA's Bloodborne Pathogen Standard?
- Immediately terminating the employee for unsafe practice
- Providing the exposed employee with post-exposure evaluation and follow-up at no cost (Correct answer)
- Reporting the incident to CMS within 24 hours
- Replacing all needles in the facility with new brand products
Correct answer: Providing the exposed employee with post-exposure evaluation and follow-up at no cost
OSHA's Bloodborne Pathogen Standard requires employers to provide free post-exposure evaluation, testing, and follow-up to exposed employees.
Question 6: What is the PRIMARY purpose of an infection control risk assessment (ICRA) in a long-term care facility?
- To document past infection outbreaks for regulatory compliance
- To identify and prioritize infection risks specific to the facility and guide prevention strategies (Correct answer)
- To calculate the facility's annual infection rate for CMS reporting
- To compare the facility's infection rates against national benchmarks
Correct answer: To identify and prioritize infection risks specific to the facility and guide prevention strategies
An ICRA proactively identifies facility-specific vulnerabilities so the infection prevention program can target resources and interventions appropriately.
Question 7: Which finding would indicate that a facility's QAPI program is effectively integrated with its infection prevention program?
- Infection data is collected but reviewed only by the infection preventionist privately
- Infection trends are analyzed at QAPI meetings and result in documented performance improvement projects (Correct answer)
- The facility purchases new PPE each year regardless of infection rates
- Hand hygiene audits are conducted but results are never shared with staff
Correct answer: Infection trends are analyzed at QAPI meetings and result in documented performance improvement projects
Effective integration means infection data drives QAPI performance improvement projects with documented goals, interventions, and outcomes.
SMQT Infection Prevention and Control 5
A surveyor discovers that a facility does not have a designated infection preventionist (IP).
Under the revised CMS Requirements of Participation, what is required?