CMS SOM App. A, Tag A-0749

policies and procedures, employs methods for preventing and controlling the transmission

of infections within the hospital and between the hospital and other institutions and

settings;

Interpretive Guidelines §482.42(a)(2)

The hospital infection prevention program must establish policies and procedures for

implementing methods of preventing and controlling the transmission of infection in the broader

sense, to include not only the hospital but between the hospital and other institutions or settings.

The development of such policies and procedures will require hospitals focus efforts to prevent

and control infections not just between patients and personnel, but also between individuals

across the entire hospital setting (for example, among patients, personnel, and visitors) as well as

between the hospital and other healthcare institutions and settings and between patients and the

healthcare environment. It is expected that hospitals consider the impact of their outpatient

facilities on their inpatient units with the development and implementation of a hospital wide

infection control and prevention program policies.

We believe this section reflects current best practices that are in place in most hospitals. The

reality is that patients move between settings with great frequency and carry organisms with

them, hence it is imperative that hospitals approach multi-drug resistant organism control from

the broader perspective in order to protect their patients and staff. A concrete example of this

already being part of current practice is that hospitals are already required to track both hospital-

and community-onset cases of CDI and MRSA, because research has shown that community

onset cases of these pathogens can impact hospitals. Hospitals should consider how they can

partner with facilities with whom they frequently share patients (e.g. nursing homes) to establish

ways to share information on patients who harbor potentially transmissible pathogens. Likewise,

the role of the environment is being increasingly recognized as an important source of infections

and this change simply reflects this data and best practices. There are many good examples of

hospitals working on preventing the spread of infection between healthcare environments. This

update also fits with the clarification that these CoPs apply to both a hospital’s inpatient and

outpatient locations.

Survey Procedures §482.42(a)(2)

• Review the hospital policies and procedures for infection control and prevention to

provide evidence that the hospital is following policies and procedures that employ the

methods for preventing and controlling the transmission of infections within the hospital

and between the hospital and other healthcare settings.

• Determine whether the infection control program is being applied throughout the

hospital to both inpatient and outpatient settings.