The churn of staff turnover and administrative changes in long-term care may make it difficult for many facilities to meet an impending federal requirement to establish infection prevention programs.

The Centers for Medicare & Medicaid Services (CMS) deadline for a designated and trained infection preventionist (IP) in long-term care facilities is Nov. 28, 2019. CMS issued a final rule1 on the requirements in 2016, with deadlines for various provisions of compliance phased in annually thereafter. CMS and the CDC are offering free training to meet this requirement, but there are signs that some long-term care facilities will struggle to comply.

IP turnover is a significant barrier in developing effective infection control programs in long-term care facilities, said Margaret Drake, MT, ASCP, CIC, infection preventionist at the Nebraska Department of Health and Human Services.

Drake presented survey results2 underscoring the problem recently in Philadelphia at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). An online survey of 222 nursing homes netted 64 responses from those with IP responsibilities at the facility. Drake and colleagues sought information on turnover in the last two years, both factors contributing to it and assessments of its effect on the IP position.

“The IP position turned over within a year 39% of the time, and by two years over half of them have left,” Drake said.

In addition, all IPs reported performing at least one additional responsibility in addition to their infection control role, some citing up to four additional duties. Workload was the most commonly cited factor for turnover, followed by compensation and nursing leadership turnover. Overall, 55% reported turnovers in director of nursing positions, which often translated to new duties and expectations under the new administrator. Survey respondents’ comments on how changes in leadership affected the IP role included:

  • “Different perspectives, priorities, and expectations;”
  • “Difference of opinion in the way things should be done [and on] the importance of infection prevention;”
  • “Lack of direction and focus on several areas of concern due to the changes in management and administration;”
  • No consistency, learning curve.

Of those reporting administrative changes, 60% said they had two directors of nursing in the last two years and 26% had three, she reported.

“You cannot continue to have a consistent program when you have a change in leadership and have to stop and turn in another direction,” Drake said.

The survey revealed 59% of the IPs in a facility had been on the job less than a year and 16% less than two years. In terms of the effect of IP turnover, some respondents said it was unclear what the previous IP did and where they should assume duties.

“There is no consistency for the staff,” she said. “Then, there is the learning curve. It takes time to not only learn what the previous person was doing, but what should even be your role as the IP.”

Drake and colleagues intervened on behalf of a nurse at one facility who had to work the night shift as well as the IP role.

“We talked to the administration and said she needs protected time,” she said. “[They] talked to her and gave her some protected time, but recently there was turnover in administration, and she is back on nights again.”

Another IP in long-term care was surprised to learn from the health department that the CMS mandate included duties beyond antibiotic stewardship, which she was told was her primary role.

“She didn’t have a desk, a computer — nothing,” Drake said. “When the administrator is not behind the IP program, it is not going to fly.”

Asked what would prevent turnover, respondents said nursing leadership stability, opportunity for professional development, and overall satisfaction.

“Some said the reason they stay is that they feel a responsibility for the residents,” Drake said. “I see that in all areas of nursing. You really feel responsible for your patients and that is who you are there for.”

Similar trends were found in another APIC study in which researchers examined skilled nursing facilities (SNFs), which have been linked to transmission of multidrug-resistant bacteria across the healthcare continuum. A pilot survey of 12 IPs in SNFs was conducted last year as part of a larger project to reduce healthcare-associated infections by improving collaboration between long-term care and hospitals.

“Over half of the 12 IPs had five years or less experience in infection prevention,” the researchers reported.3 “All of the IPs had other responsibilities such as staff education and development, occupational health, or assistant director of nursing. Ten months into the 12-month pilot year, seven of the 12 IPs had left their IP position.”

Despite the turnover, the facilities remained enrolled in the project, and the research team helped the new IPs take on the role.

“Limited IP experience and turnover will pose a significant challenge for SNFs in trying to meet CMS mandates,” the researchers concluded. “Strategies should encourage relationships with experienced IPs to assist SNFs in training and retaining IPs.”


  1. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; reform of requirements for long-term care facilities. Action: Final rule. Fed Reg Oct. 4, 2016. Available at: Accessed Aug. 9, 2019.
  2. Drake M, Nailon R, Fitzgerald T, et al. Factors associated with infection preventionist turnover in long-term care facilities. Session 2103. APIC Conference, June 13-14, 2019, Philadelphia.
  3. Jones K, Krein S, Harrod M, et al. Supporting the infection preventionist in skilled nursing facilities: Why required education is only the tip of the iceberg. Session 2103. APIC conference, June 13-14, 2019, Philadelphia.