CMS SOM App. A, Tag A-0747

Antibiotic Stewardship Programs

The hospital must have active hospital-wide programs for the surveillance, prevention, and

control of HAIs and other infectious diseases, and for the optimization of antibiotic use

through stewardship. The programs must demonstrate adherence to nationally recognized

infection prevention and control guidelines, as well as to best practices for improving

antibiotic use where applicable, and for reducing the development and transmission of

HAIs and antibiotic resistant organisms. Infection prevention and control problems and

antibiotic use issues identified in the programs must be addressed in collaboration with the

hospital-wide quality assessment and performance improvement (QAPI) program.

Interpretive Guidelines §482.42

The hospital must have an active infection control program throughout the hospital for the

surveillance, prevention, and control of Healthcare Associated Infections (HAIs) and other

infectious diseases and a program for the optimization of antibiotic use through stewardship.

These hospital-wide programs must include, at a minimum, a system for preventing, identifying,

reporting (as applicable), investigating, and controlling infections and communicable diseases

for all patients, staff, and visitors and a system for improving antibiotic use for patients.

The programs are based on the individual hospital’s assessment while demonstrating adherence

to nationally recognized infection prevention and control standards of practice, as well as to best

practices for improving antibiotic use where applicable, and for reducing the development and

transmission of HAIs and antibiotic-resistant organisms. The hospital should have written

standards, policies, and procedures and issues identified in the infection control program must

be addressed more broadly through the hospital QAPI program.

Survey Procedures §482.42

• Review policies and procedures of the infection control program for evidence that the

hospital has an active, hospital-wide program for surveillance, prevention, and control of

health associated infections and other infectious diseases based on national standards of

practice and best practices.

• Review the antibiotic stewardship program for evidence that the hospital has an active

hospital-wide program for the optimization of antibiotic use through stewardship based on

national standards of practice and best practices.

• Review the infection control program for evidence that the hospital is working

collaboratively between infection control and hospital QAPI when infection control issues

are identified.

• Review the antibiotic stewardship program for evidence that the hospital is working

collaboratively between antibiotic stewardship and hospital QAPI when antibiotic use issues

are identified.