Q&A on the ROP Phase 3 Infection Preventionist Requirement

We received several questions during our Critical Role of Infection Preventionist in LTC webinar with PDI and McKesson, and the presenter, Amanda Thornton, RN, MSN, CIC, has taken the time to respond. Read below to see the answers to the most frequently asked questions on infection control, prevention programs, and the new role required by the Centers for Medicare and Medicaid Services in Phase 3 of the Requirements of Participation (ROP) for long-term care (LTC) facilities.


Q: For the “part-time at facility” requirement, can a nurse that works full time also have the Infection Preventionist (IP) title and be IP as needed? Or do they need to spend “part time” amount as IP?

A: The guideline on this does not have a specific stated number of hours the IP must work in the facility. However, I believe the idea behind the regulation is that they want someone with “boots on the ground” in the facility to be able to make observations as well as perform ongoing infection control interventions. I believe what they are trying to avoid here is someone doing off-site oversight of the infection control program for the facility.

A good infection control program requires someone with specialized infection control training to be inside the facility. If this full-time RN is able to perform ongoing infection control tasks as part of the day’s job duties on top of other tasks of caring for residents, I believe that would qualify. For example, IP tasks would include overseeing daily monitoring of isolation of residents including signage, personal protective equipment, hand hygiene observations, ensuring compliance with infection control policies, etc. That being said, the infection control officer really needs dedicated time each week to do tasks, such as surveillance, that cannot be performed at the same time as patient care.


Q: Does this person have to be an RN?

A: No, they do not have to be an RN. The regulation states that primary training can be in nursing medical technology, microbiology, epidemiology, or another related field. A primary training in nursing is also acceptable, so an LPN should meet the regulation as well.


Q: Can the IP also be the director of nursing (DON) of the facility?

A: In long-term care, it is common that some people have to fill the job duties of several titles. There is no language within the regulation specifically prohibiting this scenario. However, I would think a surveyor would frown on this arrangement unless it is in a very small facility (for example 25 beds or smaller), and would be looking very closely during survey to ensure that the DON is also able to perform all the duties of the infection prevention and control officer.


Q: Shingles can require contact precautions, but does it require airborne precautions as well?

A: The Centers for Disease Control (CDC) gives the following answer on its website:

Infection-control measures depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated (defined as appearance of lesions outside the primary or adjacent dermatomes). In all cases, standard infection-control precautions should be followed.

If the patient is immunocompetent with


If the patient is immunocompromised with



Q: You mentioned Legionella prevention?

A: For prevention of Legionella in the water distribution system, the CDC recommends maintaining hot and cold water temperatures as mandated by state law. For the most up-to-date recommendations for healthcare facilities, the CDC also refers to ASHRAE standard for building water systems.

The facility should establish validation procedures to assure adequate biological control.  Routine testing for the bacteria should also be a part of a prevention and water maintenance program.  More information and guidance can be found at the CDC’s website.


Q: How is this prevented or spread?

A: Legionnaires’ disease (Legionella) is a type of pneumonia that is caused by inhalation of aerosolized water containing L pneumophila bacteria. Legionnaires’ disease cannot be contracted through person to person contact, but rather must be inhaled through the lungs from contaminated droplets of water. This particular type of bacteria can grow quickly under certain circumstances and if aerosolized the bacteria can pose a great risk to human health.

The bacteria also can cause Pontiac fever, a milder form of the disease which most often resembles the flu.  The two diseases together are called legionellosis. Prompt treatment with antibiotics will usually clear and cure the disease.


Q: Where can I get an annual report checklist for laundry?

A: The parameters, requirements and checklist can be found on the CDC’s website.


Q: Regarding residents with colonized extended spectrum beta-lactamases (ESBLs), methicillin-resistant Staphylococcus aureus (MRSA), etc., in the wound or urine, do they need to be in contact precautions?

A: Unfortunately, there is very little guidance out there for the discontinuation of contact precautions and ultimately it is up to the facility and the internal policies they establish. Many facilities have specifics around the discontinuation of contact precautions based on their internal risk assessment. For example, if MRSA is a big issue within the facility, they may have more stringent guidelines around the discontinuation of contact precautions for that particular organism versus other organisms that the facility may not struggle at controlling as much. Although not specific to long-term care, the Society for Healthcare Epidemiology of America (SHEA) did release some updated expert guidance on this subject in 2018 for acute care facilities. This may provide some guidance you can follow or point you in the right direction for writing policies around this issue.


Q: What should be used to clean rehab equipment between residents?

A: PDI offers a wide range of acceptable healthcare grade disinfectants that are EPA registered and approved for disinfection in long-term care.  I recommend PDI’s Super Sani-Cloth, which would be acceptable to use on rehab equipment between residents.  As always however, the instructions for use on each piece of equipment should be followed.  Occasionally manufacturers of equipment will specify the exact brand of disinfectant that is approved for use on their equipment.  It is the responsibility of the facility to ensure they are following all manufacturers’ instructions.


Q: For the new F tag of infection preventionist, if I have had previous training from the California Department of Public Health (CDPH) basic boot camps and also a paid two-day course is that suitable for the F tag? Or should I be on the safe side and do the CDC TRAIN course?

A: The requirement states that you must have state-sponsored training or training from approved nationally recognized agencies such as SHEA or the Association for Professionals in Infection Control and Epidemiology.  If the CDPH boot camp was a state-sponsored infection control training, it may meet the requirement. However, to be on the safe side, it would not hurt to do the free training through the CDC TRAIN website.

Amanda Thornton

Clinical Science Liaison, PDI

Amanda joins PDI from Kindred Hospital, where she was Chief Clinical Officer, Infection Control and Employee Health Nurse, and West Region Resource ICP for eight years where she utilized her skills in epidemiology and clinical management to reduce healthcare associated infections and increase patient safety. She also served as Corporate Nurse Quality Consultant and Infection Preventionist for the Aurora InnovAge Greater Colorado PACE program and as an instructor and program coordinator of the LPN/CNA programs of Uintah Basin Applied Technology College in Vernal, Utah. Amanda earned her Bachelor of Science in Nursing at University of Northern Colorado and her Master of Science in Nursing - Emphasis in Infection Control and Epidemiology at American Sentinel University. She is board certified in infection control through CBIC (CIC).

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