CMS SOM App. A, Tag A-0748

and policies. The hospital must demonstrate that:

(1) An individual (or individuals), who is qualified through education, training, experience,

or certification in infection prevention and control, is appointed by the governing body as

the infection preventionist(s)/infection control professional(s) responsible for the infection

prevention and control program and that the appointment is based on the

recommendations of medical staff leadership and nursing leadership;

Interpretive Guidelines §482.42(a)(1)

Individuals responsible for the hospital infection prevention and control program are often

referred to as “hospital epidemiologists (HEs),” “infection control professionals (ICPs)” and/or

“infection preventionists.” CDC has defined “infection control professional” as “a person whose

primary training is in either nursing, medical technology, microbiology, or epidemiology and

who has acquired specialized training in infection control.”

The hospital must designate an individual or group of individuals as its infection

preventionist(s)/infection control professional(s). The individual(s) must be appointed by the

hospital governing body based on the recommendations of the medical staff leadership and

nursing leadership. The hospital should ensure high-level hospital clinical leadership,

specifically leadership from the medical staff and the nursing service, are involved in the process

of selecting the infection preventionist(s)/ infection control professional(s). This high-level

participation promotes a hospital-wide culture of safety and quality in which input across the

hospital is solicited and acted upon.

In designating infection preventionist(s)/infection control professional(s), hospitals should

assure that the individuals so designated are qualified through education, training, experience,

or certification in infection prevention and control.

CMS does not specify either the number of infection preventionist(s)/infection control

professional(s) to be designated or the number of infection preventionist(s)/infection control

professional(s) hours that must be devoted to the infection prevention and control programs.

However, resources must be adequate to accomplish the tasks required for the infection

prevention and control program. In hospitals with more than one infection

preventionist(s)/infection control professional(s), the staff members should work as an integrated

team to ensure the functions of an infection prevention and control program are covered. A

prudent hospital would consider patient census, characteristics of the patient population, and

complexity of the healthcare services it offers in determining the size and scope of the resources

it commits to infection prevention and control.

Survey Procedures §482.42(a)

• Determine whether an infection preventionist(s)/infection control professional(s) was

appointed by the governing body based on recommendations of the medical staff

leadership and nursing leadership and has the responsibility for the infection prevention

and control program.

• Review the personnel file of the infection preventionist(s)/infection control

professional(s) to determine whether he/she is qualified through professional education,

training, experience, or certification to oversee the infection prevention and control

program.

• Review the criteria the hospital used to determine the resources necessary to operate

effectively and ensure the resource allocation matches the determined needs.