What a Fractional Infection Preventionist Can Do for Your Facility

By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services

Key Takeaways

• A fractional infection preventionist provides expert infection prevention support on a defined scope and schedule, without the cost and commitment of a full-time hire.

• Hospitals and critical access hospitals can appoint a qualified outside consultant as their infection preventionist, and ambulatory surgery centers can designate one when onsite time meets surveyor expectations.

• Fractional support also strengthens an existing program through mentoring, specialized expertise, and coverage during turnover or leave.

• Ongoing work typically includes surveillance and reporting, policy updates, practice audits, staff education, and survey readiness.

• Smaller facilities with limited local recruiting options, including critical access hospitals, federally qualified health centers, surgery centers, and physician practices, tend to benefit most.

Every healthcare facility needs a qualified professional leading its infection prevention program, but many lack the workload to justify a full-time infection preventionist, the budget to fund one, or a local talent pool to recruit from. A small rural hospital may go months without a viable applicant. A surgery center may hand the role to a nurse who already manages the operating room schedule. For these facilities, a fractional infection preventionist is a practical alternative to a full-time hire.

1. What Fractional Means in Infection Prevention

A fractional infection preventionist is an experienced infection prevention professional who works for your facility part-time under an ongoing agreement. The scope, schedule, and deliverables are set in advance, and the work continues month after month. You may also see the arrangement described as fractional infection control support or fractional infection control consultants.

Most of the work happens remotely: reviewing surveillance data, updating policies, joining committee meetings by video, and answering staff questions as they come up. Onsite visits cover the tasks that require direct observation, such as environmental rounds, sterile processing reviews, and hands-on staff education. The balance between the two depends on the facility's needs and any onsite expectations set by regulators.

2. Serving as Your Designated Infection Preventionist

The Centers for Medicare & Medicaid Services (CMS) requires hospitals and critical access hospitals (CAHs) to have their governing body appoint an infection preventionist qualified through education, training, experience, or certification in infection prevention and control. The CMS Conditions of Participation define the qualifications for the role. They do not require the infection preventionist to be an employee or to work a minimum number of hours. A fractional infection preventionist can hold the appointment, provided the facility documents it and the responsibilities assigned to the role get done: surveillance, policy development, staff education, auditing of practices, and collaboration with the quality assessment and performance improvement (QAPI) program.

At some critical access hospitals (CAHs) we support, an ICCS consultant serves as the hospital's primary infection preventionist, taking on the full scope of tasks an onsite or in-house infection preventionist would perform. That includes but is not limited to identifying healthcare-associated infections (HAIs), reporting to state and federal agencies through the National Healthcare Safety Network (NHSN), developing, reviewing and revising policies, attending meetings virtually,  coordinating quality and performance improvement projects, and liaising with the clinical staff member assigned to manage acute issues or emergencies.

Ambulatory surgery centers (ASCs) follow a similar rule. The Conditions for Coverage require a designated professional with training in infection control to direct the program, and CMS surveyor guidance expects that person to be a licensed healthcare professional who spends enough time onsite for the center's size and surgical volume. Many ASCs designate a nurse on staff and use fractional support to oversee and strengthen the program. An outside consultant can hold the designation when the onsite schedule meets that expectation.

Whichever model you choose, put the designation in writing, have your governing body approve it, and keep documentation of the designee's qualifications on file. Some states add requirements such as certification, so confirm your state's rules before finalizing the arrangement.

3. Supporting an Infection Preventionist Already on Staff

Many facilities already have someone in the infection preventionist role, often a nurse who took on infection prevention alongside other duties with little formal training. A fractional infection preventionist can mentor that person, review their work, and help them build the knowledge to run the program with confidence. At ICCS, we provide this through structured infection preventionist onboarding and mentoring.

Fractional support also adds depth in areas where even experienced staff may have limited exposure. Sterile processing, high-level disinfection, outbreak investigation, and accreditation readiness all call for specialized knowledge that a generalist role seldom develops. A consultant with that background can review these areas before surveyors do.

4. Covering Turnover, Leave, and Vacancies

When an infection preventionist resigns, retires, or goes on extended leave, the program's requirements stay in place. Surveillance still has to be completed, NHSN reports are still due, and surveyors can arrive at any time. Recruiting a qualified replacement can take months, especially in rural communities.

A fractional infection preventionist can step in quickly and keep the program on track during the search. Once a new hire starts, the same consultant can shift into a mentoring role, which shortens the learning curve and preserves continuity. Some facilities find the interim arrangement works well enough to keep permanently.

5. What the Work Looks Like Month to Month

The exact scope depends on the facility, but a typical engagement includes:

• Surveillance for HAIs and required reporting to NHSN and state agencies

• Review and revision of infection prevention policies and procedures as guidelines change

• Participation in infection prevention, QAPI, and other committee meetings

• Audits of hand hygiene, environmental cleaning, and other practices, with results reported to leadership

• Staff education and competency training

• The annual infection prevention risk assessment and program evaluation

• Ongoing survey readiness, so the facility is prepared whenever surveyors arrive

Between scheduled tasks, the consultant serves as a resource for day-to-day questions. When a staff member is unsure about a new disinfectant, an exposure, or an unusual cluster of infections, they have someone to call.

6. Facilities That Benefit Most

Fractional support fits any facility where the infection prevention workload is steady but does not fill a full-time position. That description covers many of the settings we work with:

• Critical access hospitals, where recruiting a certified infection preventionist to a rural community is often the hardest part

• Federally qualified health centers (FQHCs), which need a compliant infection prevention program across every clinic site

• Ambulatory surgery centers that want specialized depth behind the staff nurse designated to direct the program

• Micro-hospitals, which must cover the full program with a small clinical staff

• Imaging centers and physician practices with reprocessing, high-level disinfection, or procedural risks to manage

Final Thoughts

Some facilities have enough infection prevention work to support a full-time hire. Many smaller facilities do not, and a fractional arrangement gives them infection prevention leadership scaled to their workload. Whether you need someone to hold the role, support the person who already does, or cover a vacancy, ICCS can build an arrangement around your facility.

Our fractional infection control consultants work with CAHs, ASCs, FQHCs, and other healthcare facilities nationwide. If you are still deciding whether outside help makes sense, review the signs it may be time to turn to infection control consultants, or schedule a complimentary consultation to talk through your facility's needs.

Frequently Asked Questions About Fractional Infection Preventionists

Can a fractional infection preventionist serve as our designated infection preventionist?

In many settings, an outside consultant can hold the role. CMS requires hospitals and critical access hospitals to appoint a qualified infection preventionist but does not require that person to be an employee or to work a set number of hours. ASCs can also designate an outside consultant. In every case, the governing body should approve the designation in writing, and the facility should confirm any additional state requirements.

How much of the work is done remotely?

Most ongoing work, including surveillance review, NHSN reporting, policy updates, and committee participation, can be handled remotely. Occasional or established onsite visits, such as twice-yearly or quarterly visits, are typically scheduled for a comprehensive review of hands-on processes, staff education, and assistance with upcoming survey preparation.

How is fractional support different from a one-time consulting engagement?

A one-time engagement addresses a defined project, such as a risk assessment, mock survey, or plan of correction, and ends when the deliverable is complete. Ongoing support continues over time, with the same consultant maintaining the program between surveys and getting to know the facility's staff and operations. Many facilities start with a single project and move into an ongoing arrangement afterward.

Can support increase before a survey or after a deficiency?

The arrangement can scale up when a facility's needs change, such as in the weeks before an accreditation or state survey, during an outbreak investigation, or after a survey results in deficiencies that require a plan of correction. Support can return to its usual level once the program is stable.

Does a fractional infection preventionist need to be certified?

Federal rules do not require certification. CMS requires hospital and CAH infection preventionists to be qualified through education, training, experience, or certification, and requires ASCs to designate a professional with training in infection control. Some states set stricter standards, and Certification in Infection Control (CIC) from the Certification Board of Infection Control and Epidemiology (CBIC) is the most widely recognized credential in the field. While not mandated, the CIC is considered the national gold standard and signifies a level of training, experience, and expertise.

Year-End Infection Control Tasks for Healthcare Facilities

By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services

Key Takeaways

• Update your infection control risk assessment and confirm this year's goals, and make sure annually renewed policies, including your exposure control and bloodborne pathogens plans, are current.

• Validate technical competencies: Review your water management plan and Legionella risk assessment against ANSI/AAMI ST108, and confirm sterilization and high-level disinfection (HLD) competencies are documented.

• Reconcile your NHSN surveillance data and reassess your antimicrobial stewardship program against current CMS and accreditation requirements.

• Review hand hygiene compliance trends and schedule a mock survey or environmental rounds if you haven't had one this year.

• Check your policies against new guidance issued this year, and start budget conversations now for next year's infection prevention and control support.

Every fall, I start hearing from facilities that want a mock survey done before the holidays or a risk assessment updated before their books close for the year. Whatever the end of the year looks like at your facility, a handful of infection prevention and control tasks are worth finishing before January rather than carrying into next year's survey cycle. None of these tasks are complicated on their own. They get difficult when several land in the same few weeks or months, on top of everything else your team is handling.

1. Update Your Infection Control Risk Assessment and Annual Goals

Your infection control risk assessment should reflect what happened this year. Too many facilities treat it as a formality and leave it matching whatever they wrote back in January. Look at the goals you set alongside it. If you met them, decide what comes next. If you didn't, figure out why before the same target carries forward unchanged. This is also the moment to flag anything new, such as a renovation, new equipment or a change in service lines, that should shape next year's risk priorities.

2. Confirm Annual Policy and Plan Renewals Are Current

Several plans carry an annual review requirement, and it's easy to let a review date slip when there's no dedicated compliance calendar tracking it. Lapses tend to show up in:

• Bloodborne pathogen exposure control plan

• TB exposure control plan and TB risk assessment

• Facility-specific policies tied to your annual review cycle

Check your full policy list against requirements for your facility setting. A policy with an outdated review date is a deficiency waiting to happen during your next survey.

3. Review Your Water Management Plan Against ANSI/AAMI ST108

Water management plans and Legionella risk assessments (RA) need periodic review even in years when nothing obviously changed. Facilities that provide services requiring reprocessing of instruments and devices (e.g. surgical services) including outpatient surgery centers, acute care hospitals, critical access hospitals (CAHs), and micro-hospitals should confirm their plan reflects ANSI/AAMI ST108, the current standard from the Association for the Advancement of Medical Instrumentation (AAMI) governing water quality for device reprocessing. I still occasionally run into plans that cite guidance from AAMI TIR34:2014/(R)2021, which ST108 has since replaced, sometimes years after the update.

4. Validate Sterilization and High-Level Disinfection Competencies

Sterile processing staff need periodic competency validation, and it's one of the more commonly cited findings I see across central sterile processing departments regardless of facility type. Before the year ends, confirm every staff member with reprocessing responsibilities has current, documented competency validation performed by a professional with training in reprocessing. Initial training from years ago doesn't carry forward on its own.

5. Reconcile Your NHSN Surveillance Data

If your facility reports to the National Healthcare Safety Network, or NHSN, year-end is when I tell clients to reconcile their data rather than wait for a submission deadline to surface a problem.

6. Reassess Your Antimicrobial Stewardship Program

Antimicrobial stewardship is a CMS requirement for acute care hospitals, CAHs, and long-term care facilities (LTCFs), and accreditation organizations tend to maintain their own related standard. Programs should be reassessed against current requirements every year. Even a program that was designed correctly at launch can move out of alignment and compliance as guidance changes. If your antimicrobial stewardship program hasn't been reassessed in a while, now is a good time to check that box.

7. Pull Your Hand Hygiene Compliance Data

Hand hygiene data gets collected at most facilities I work with. Reviewing it closely enough to catch a pattern happens less often. Before the year closes, pull your trends and look for a pattern, such as a unit that consistently underperforms or a shift with noticeably lower numbers than the rest. That pattern gives you something concrete to act on heading into next year, which is much more useful than a single overall percentage. Hand hygiene remains the foundation of Standard Precautions, so any concerning trend is worth following up on and acting on.

8. Schedule a Mock Survey or Environmental Rounds

If your facility hasn't had a mock survey or a full round of environmental observations this year, don't let it slip into next year unscheduled. I run these visits specifically to catch what staff walk past every day without noticing. A mock survey gives you that outside perspective while there's still time to act on it.

9. Check for New CDC, CMS, or Accreditation Agency Guidance

CDC, CMS, and accreditation agencies may issue updates throughout the year, and I've seen facilities miss one simply because nobody was assigned to track it. Set aside time before the end of the year to compare your policies against what changed this year, rather than assuming everything is still current.

10. Start Budgeting for Next Year's Infection Control Support

If outside support is going to be part of next year's plan, start that conversation early. Waiting until the need is urgent narrows your options. A few things possibly worth budgeting for:

• Survey preparation, if one is anticipated in the next six months to a year

• Additional staffing or outside support where your team needs the coverage; this may include fractional support if your organization would benefit from ongoing expert oversight

• Program-specific initiatives planned for next year, like a major risk assessment or onboarding and mentoring of new infection prevention staff

Budget cycles move slower than project timelines, and facilities that wait until they need help are often waiting longer than they'd like.

Final Thoughts

These 10 tasks can be straightforward individually. They get hard to manage when facilities wait until the final few weeks of the year to tackle all of them at once, after everything else on the calendar is already set. Starting now gives you room to get through the list without rushing. If it turns up more work than your team can handle internally before year-end, contact ICCS and my team will help you sort out what should happen, when, and where we can help.

Frequently Asked Questions About Year-End Infection Control Tasks

What is the most important task to finish before year-end?

If you only get through one, consider making it the infection control risk assessment, sometimes called an ICRA and distinct from the construction-specific risk assessment of the same name, and goals review. Everything else on this list can be easier to prioritize once you know where your program stands and what changed over the past year.

How far in advance should we start budget conversations for next year's infection control needs?

Start well before year-end if possible. Budget approvals and vendor scheduling both take longer than most facilities expect, and firms that get requests earlier in the fall have more flexibility than those calling in January, when demand picks up.

Is a mock survey necessary every year?

It depends on your accreditation agency’s survey cycle and how confident you are in your program's current state. I recommend a mock survey now for any facility due for survey in the next 6 to 12 months, but even facilities with more runway tend to find value in a fresh set of eyes at least once a year.

What happens if a facility doesn't get through this list before January?

Nothing happens automatically, but the tasks don't disappear. They just get harder to prioritize once new items start competing for attention in the new year. I'd rather see a facility work through even a few of these before year-end than start January from zero.

Do these tasks apply to every type of facility?

Most of them apply broadly, though a few carry facility-specific nuances. It's worth checking a given requirement against your specific facility type and accreditation agency, since requirements can differ meaningfully between, for example, an ambulatory surgery center and a critical access hospital.

Signs It's Time to Turn to Infection Control Consultants

By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services

Key Takeaways

• A risk assessment more than a year old, or one that's never been completed, is already a compliance issue on its own.

• Facilities that assign infection control to staff already covering other roles typically see slower surveillance and incomplete documentation.

• A survey citation or plan of correction is a lagging indicator. The warning signs are usually visible months earlier.

• Turnover in the infection preventionist role costs more than staffing continuity, in part because it resets institutional knowledge each time.

• Sterile processing and water management remain two of the most frequently cited areas across ambulatory and outpatient surveys.

• A recent outbreak or infection cluster, even a small or contained one, is one of the clearest signals it may be time to bring in specialized support.

• Infection control consultants can address any one of these issues and others directly, without the cost or timeline of a full-time hire.

Facilities rarely decide to bring in outside infection control help because everything is running smoothly. Usually what triggers the outreach is a problem that surfaces, such as a missed deadline, a survey finding, and a staff member who gave notice. Below are some of the signs we at Infection Control Consulting Services see most often across the facilities we serve, including ASCs, hospitals, FQHCs, imaging centers, and CAHs, before a facility reaches out for assistance from infection control consultants.

Quick self-check. If any of these describe your facility right now, it's worth a conversation:

• Your last infection prevention risk assessment was more than a year ago, or never happened.

• No one on staff is dedicated to infection control full time.

• Your infection preventionist left recently, or is planning to.

• You haven't run a mock survey against your accrediting body's current standards in the past year.

• You've received a citation or are struggling to work through a plan of correction.

• Sterile processing or your water management plan hasn't been reviewed recently.

• You've had a recent outbreak or infection cluster, however small.

Your Last Risk Assessment Was More Than a Year Ago

Annual infection prevention risk assessments are one of the most effective ways for a facility to identify where its actual exposure sits, from sterile processing to hand hygiene compliance to water management. When a risk assessment is overdue or was never completed with the depth surveyors expect, that oversight tends to surface at the worst possible time: during a survey.

A thorough risk assessment typically covers areas including, but not limited to:

• Sterile processing and reprocessing practices

• Hand hygiene compliance and observation data

• Water management and environmental controls

• Isolation precautions and PPE use

• Documentation and surveillance processes

If your facility can't point to a current risk assessment covering these areas, that's reason enough on its own to bring in outside support.

No One Owns Infection Control Full Time

Many facilities, particularly smaller hospitals, ASCs, and outpatient care sites, assign infection prevention to a nurse, quality manager, or administrator who is already covering other responsibilities. Surveillance, policy review, staff education, and reporting each take real time, and none of them get easier when the person responsible for them is also managing three other jobs. Inevitably, documentation and training slip, and trends in infection data can go unnoticed until they become outbreaks.

Infection control consultants often offer onboarding and mentoring support for facilities building this role from scratch, along with ongoing education for staff who have inherited infection control responsibilities without formal training.

You've Had Recent Turnover in Infection Control Leadership

When an infection preventionist leaves, their knowledge of your facility's specific processes, history, and open issues leaves with them. Rebuilding that institutional knowledge takes time your compliance timeline may not allow. Our look back at 2025's infection prevention challenges covered this directly: Facilities that lost dedicated infection preventionists to burnout or turnover saw gaps in oversight and inconsistent surveillance follow through in the months after.

Infection control consultants provide continuity a single hire can't guarantee. If the person leaves, the program doesn't leave with them.

You Haven't Conducted a Mock Survey Recently

Accreditation and CMS surveys are unannounced, whether your facility is surveyed by CMS directly, Joint Commission, AAAHC, ACHC, QUAD A, DNV or CIHQ. Facilities that wait until a survey letter arrives to assess their readiness are already behind. A mock survey is one of the most effective ways to identify problematic areas while there's still time to correct them, rather than after a surveyor has documented a deficiency.

A mock survey typically evaluates key areas like:

• Written infection prevention program documentation against current standards

• Sterile processing and reprocessing workflows

• Injection safety and medication handling practices

• Staff knowledge of policies during direct observation

• Prior survey findings, to confirm they were fully resolved and not just noted as closed

If it's been more than a year since your facility ran a mock assessment against your accrediting body's current standards, survey preparation support is worth scheduling now rather than after your next survey window opens.

You've Received a Citation or Must Submit a Plan of Correction

We view citations as a "lagging indicator." By the time a deficiency is documented by a surveyor, the underlying issue has likely existed for months. This shows up across accreditors, not just one. In AAAHC's 2026 Quality Roadmap, for example, infection control practices ranked among the leading causes of Immediate Jeopardy findings in ambulatory and primary care surveys, second only to crash cart readiness. Similar patterns turn up in survey data from other accrediting bodies as well. While written policies may exist, the oversight and follow-through behind them often don't.

If your facility is working through a plan of correction, the priority is making sure the underlying process changes, not just your paperwork.

Sterile Processing or Water Management Hasn't Been Reviewed Recently

Sterile processing and water management are two of the areas surveyors scrutinize most closely, and two of the easiest to let slip when internal resources are stretched. Water management plans built to AAMI ST108 standards and regular observation of sterile processing workflows both require a level of specialized attention that's difficult to sustain internally at smaller and sometimes even larger facilities.

ICCS's infection control consultants provide direct sterile processing guidance and water management plan development for facilities that need both reviewed against current standards.

You've Had a Recent Outbreak or Cluster

A cluster of surgical site infections, a multidrug-resistant organism identified in more than one patient, or any pattern that looks like more than an isolated case calls for an outbreak investigation. Identifying the source, confirming whether transmission is ongoing, and implementing corrective action quickly all affect patient safety, public reputation, and how a subsequent survey or regulatory review goes.

An outbreak is often the most urgent sign on this list that a facility would benefit from an infection control consultant. It's also the one facilities are generally least prepared to handle internally, since outbreak investigation requires a specific skill set most facilities don't need often enough to keep in-house.

Final Thoughts

None of these signs alone points to a crisis. Together, they're the pattern we see most consistently right before a facility reaches out. Some clients bring ICCS in to support an infection preventionist who's already on staff. Others use our fractional infection control consultants to cover the role entirely, particularly at facilities where a full-time hire isn't realistic. Both are legitimate approaches, and the right one depends on your facility's size, resources, and current program.

The ICCS team of infection control consultants supports a wide range of facility types. Please schedule a complimentary consultation to talk through what your facility needs.

Frequently Asked Questions on Infection Control Consultants

How do I know if my facility needs infection control consultants or just more internal training?

If the issue is limited to staff knowledge, such as hand hygiene compliance or documentation practices, targeted training may be enough. If it involves program structure, regulatory readiness, or specialized areas like sterile processing and water management, that typically calls for outside infection control expertise with survey and accreditation experience.

Can infection control consultants help after a citation has already been issued?

Yes. This is one of the most common reasons facilities reach out to ICCS. Infection control consultants can help develop and implement a plan of correction, and more importantly, address the underlying process gaps so the same issue doesn't recur at the next survey.

Do infection control consultants replace the need for an infection preventionist on staff?

Not necessarily. Many facilities use consultants to support an existing infection preventionist, cover gaps during turnover or leave, or provide fractional oversight when a full-time hire isn't feasible. Others use consultants to build a program from the ground up before hiring internally.

What's the difference between an infection preventionist and infection control consultants?

An infection preventionist is typically an internal staff member responsible for day-to-day surveillance, education, and program management at a single facility. Infection control consultants work externally, often across multiple facilities, and bring broader survey and regulatory experience along with the flexibility to scale support up or down as a facility's needs change. Many facilities use both, with consultants supporting or mentoring the internal infection preventionist rather than replacing that role.

Do accreditation organizations like AAAHC, Joint Commission, or ACHC require facilities to use infection control consultants?

Typically, an agency or accrediting body does not require a facility to contract with an outside consultant. What they do require is a compliant infection prevention and control program, led by a qualified, designated professional, that meets current standards. Consultants are one way facilities meet that requirement when internal resources or expertise fall short, regardless of which accrediting body oversees the facility. However, depending on the type of survey and the accreditation organization or agency (particularly CMS), a certified consultant may be required.

How quickly can infection control consultants get started?

This depends on the scope of the engagement, but ICCS typically begins with a complimentary consultation to understand the facility's current state, followed by an on-site or remote assessment. Facilities preparing for an upcoming survey should reach out as early as possible to allow time for meaningful corrective action.