Infection Control: Different Strokes for Different Folks

hands holding a surgical mask
By Nancy J. Beckley, MS, MBA

The COVID-19 pandemic and declared public health emergency (PHE) over the past year-and-a-half has prompted the US Centers for Medicare and Medicaid Services (CMS), the US Centers for Disease Control (CDC), the World Health Organization (WHO), and countless local and state health authorities to issue a variety of guidance.

CMS has defined, refined, and updated their infection control interpretive guidelines for therapy practices that are certified as Rehab Agencies or Comprehensive Outpatient Rehabilitation Facilities (CORFs). No such guidance exists for therapy practices that are enrolled in Medicare as a physical therapist in private practice or PT/OT group practice.


CMS has a long history of establishing variances on rules and regulations for outpatient therapy differentiated by enrollment: CORFs and Rehab Agencies enroll as a provider of services to Medicare Part A. Physical therapists in private practice enroll as a supplier of services to Medicare. Good, bad, or indifferent, there are many examples of different rules and sub-regulatory guidance for a rehab agency or CORF practices than the rules for a physical therapy private practice. But let’s get to something that seems to be at the heart of patient and public safety: infection control. Even though we hopefully have this pandemic under control, some of the rules and regulations that were developed over the past 18 months may continue or inform they may future CMS policy decisions.


In early 2020, most therapy practices experienced state mandates (Governor’s Orders) related to temporary clinic closures and/or mandated processes for continuing to serve therapy patients for medically necessary physical therapy at the start of the pandemic and PHE. These mandates included restrictions related to capacity control, masking, patient and staff screening, definition of “essential services,” elective vs. non-elective procedures, and other restrictive measures imposed by local city and county health departments.

By the end of March 2020, CMS issued guidance to outpatient certified providers including rehab agencies and CORFs. QSO Memo 20-22 advised CORFs and rehab agencies to take appropriate action to address potential and confirmed COVID-19 cases and discussed recommendation to mitigate transmission including screening, restricting visitors, cleaning and disinfection, and possible closures.1 All and all, including reference links to the CDC, this guidance was helpful to rehab agencies and CORFs in establishing supplemental infection control policies, procedures, and processes in what was quickly becoming uncharted territory. No such guidance was issued to outpatient therapy clinics enrolled in Medicare as a private practice.


December 30, 2020 CMS established a complex checklist titled COVID-19 Focused Infection Control Survey Tool: Acute and Continuing Care to guide CORFs and Rehab Agencies in establishing infection control policies and procedures. The document outlines that all rehab agencies should, in accordance with CMS current (and continuing) updated guidance, conduct a risk assessment of their policies and procedures paying particular attention to infection control and emergency preparedness. Rehab Agency policies and procedures are typically reviewed on an annual basis during the “annual meeting” of the professional committee of the rehab agency. Under the current PHE rehab agencies are advised to have the professional committee meet as often as necessary based on updated guidance from not only the CDC and CMS, but also local and state health authorities.

While these guidelines don’t necessarily apply to outpatient private practice, Table 1 identifies the policy areas highlighted by the checklist and my suggestions for policies, procedures, and processes. The list is not exhaustive, nor does each item require a separate policy, as some are easily combined into existing policies and procedures.


Table 1 offers suggestions on reviewing, updating, and adding policies, procedures, and processes. Organizing policies seems more logical when mapping to the infection control, emergency preparedness, administrative management and program evaluation conditions of participation. After all, that is what drives the surveyor checklist! Suggestions to consider for each area based upon CMS guidance and requirements:

Infection Control

  • Documentation of screenings
  • Laundering of cloth face masks
  • Listing of local COVID-19 testing sites
  • Documentation of reporting suspected or confirmed diagnosis of COVID-19 to the local health department and the accreditation organization
  • Returning to work after exposure
  • PPE Inventory and Supply monitoring and usage (optimization)
  • Disinfectant is appropriate for healthcare & effective against SARS-COV-2
  • Waiting room “empty”
  • “High-touch” items removed, drinking fountains closed
  • PPE donned during cleaning

Emergency Preparedness

  • Update All-Hazards Risk Assessment to include Pandemic and Emerging Infectious Diseases
  • Update Emergency preparedness Plan to include COVID-19 Response
  • Document Activation of Emergency Preparedness Plan and an after-action report or “hotwash”

Administrative Management

Patient care policies
  • Patient scheduling, cancellations and no shows, and deferring non-emergent care
  • Patient volume and traffic “flow” in the clinic
  • Visitor policy to include caregivers, transporters, translators
  • Telehealth
Personnel policies (with guidance from your HR source)
  • Employment law issues
  • State and local health department reporting
  • Job description updates
  • Returning to work after exposure

Program Evaluation

  • Monitoring and documenting infection control compliance
  • Weekly audit report of infection control compliance


If you managed to make it through my review of all the substantial requirements for policy, procedure, and processes noted here, you may be heaving a sigh of relief that you are a private practice. Right? Or Not? It’s been over 20 years since private practices were subject to survey and certification While CMS has not formally signaled to private practice physical therapists, best practice would seem to indicate a preference for establishing, maintaining, and documenting a robust infection control and emergency preparedness program. The path has been laid out by CMS, and while not required for private practice, offers an opportunity to conduct a risk assessment and adapt infection control practices and emergency preparedness consistent with CMS, CDC, and community standards. 


1US Centers for Medicare & Medicaid Services. Guidance for Infection Control and Prevention of Coronavirus Disease (COVID19) in Outpatient Settings: FAQs and Considerations. Published March 30, 2020.

Nancy J. Beckley, MS, MBA

Nancy J. Beckley, MS, MBA, is a compliance consultant located in Milwaukee, Wisconsin. She can be reached at and @nancybeckley.

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