Case Study: Behavioral Health Hospital at Risk of Losing Medicare License


A behavioral health hospital in the Southwest had an unfortunate set of circumstances: sudden, rapid turnover of infection prevention team members resulted in inconsistencies with policies and practices. During an accreditation survey, many deficiencies were noted, including inadequate qualifications of infection prevention staff, incomplete risk assessment and lack of education of employees.


Infection Control Consulting Services (ICCS) was engaged by the hospital CEO and director of nursing to assist in an emergency situation as the facility had only 30 days to remediate deficiencies. 


  • Reviewed and revised entire infection prevention written program.
  • Developed and implemented an infection prevention risk assessment.
  • Reviewed and revised infection prevention policies as they pertain to behavioral health.
  • Mentored an in-house employee who was designated to oversee infection prevention.
  • Provided off-site educational programs for staff on topics including the fundamentals of infection transmission prevention. 
  • Participated in the infection prevention committee meetings from a remote location.


The hospital received full accreditation upon a return visit and has since been through an additional survey with outstanding results. The surveyors were very pleased with the written program, risk assessment, training of staff and the services provided by ICCS. The hospital continues to engage ICCS for ongoing support and guidance.