CMS SOM App. A, Tag A-0750

prevention, and control of HAIs, including maintaining a clean and sanitary environment

to avoid sources and transmission of infection, and addresses any infection control issues

identified by public health authorities; and

Interpretive Guidelines §482.42(a)(3)

The hospital must provide and maintain a clean and sanitary environment to avoid sources and

transmission of infections and communicable diseases. All areas of the hospital must be clean

and sanitary. This includes all hospital departments and off-site locations. The infection

prevention and control program should include appropriate monitoring of housekeeping,

maintenance (including repair, renovation and construction activities), and other activities to

ensure that the hospital maintains a sanitary environment. Examples of areas to monitor would

include the hospital’s: onsite laundry facilities, food storage, preparation, serving and dish

rooms, refrigerators, ice machines, air handlers, autoclave rooms, venting systems, inpatient

rooms, treatment areas, labs, waste handling, surgical areas, supply storage, equipment

cleaning, etc.

CMS expects Medicare certified hospitals to have water management policies and procedures to

reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building

water systems. An industry standard calling for the development and implementation of water

management programs in large or complex building water systems to reduce the risk of

legionellosis was published by American Society of Heating, Refrigerating, and Air Conditioning

Engineers (ASHRAE). The CDC and its partners developed a toolkit to facilitate implementation

of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html).

Environmental, clinical, and epidemiologic considerations for healthcare facilities are described

in this toolkit.

To ensure that water is not the source of infections, hospitals should consider implementing a

water management program that considers the ASHRAE industry standard and the CDC toolkit.

A documented water management program includes a hospital risk assessment to identify where

Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter,

Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and

spread in the hospital water system. In addition, the water management program should specify

testing protocols and acceptable ranges for control measures, and document the results of

testing and corrective actions taken when control limits are not maintained.

The hospital must conduct surveillance on a hospital-wide basis in order to identify infectious

risks or communicable disease problems at any particular location. This does not imply all

areas and locations of the hospital at all times, but it does mean that the hospital must have

reliable sampling or other mechanisms in place to permit identifying and monitoring infections

and communicable diseases occurring throughout the hospital’s various locations or

departments. The hospital must document its surveillance activities, including the measures

selected for monitoring, and collection and analysis methods. Surveillance activities should be

conducted in accordance with recognized infection control surveillance practices, such as those

set forth by the CDC’s National Healthcare Safety Network (NHSN).

The hospital should know how to recognize and contain infectious disease outbreaks. An

outbreak is the occurrence of more cases than expected in a given area or among a specific

group of people over a particular period of time. In the event of an outbreak of an infectious

disease, hospitals should have policies and procedures in place to address the appropriate steps

to diagnose and manage cases, implement appropriate precautions, and prevent further

transmission of the disease as well as documentation of follow-up activity in response and

comply with state and local public health authority requirements for identification, reporting,

and containing communicable diseases and outbreaks.

Survey Procedures §485.42(a)(3)

• Observe the hospital for the sanitary condition of their environments of care, noting the

cleanliness of patient rooms, floors, horizontal surfaces, patient equipment, air inlets,

mechanical rooms, food service activities, treatment and procedure areas, surgical areas,

central supply, storage areas, medication preparation etc.

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

program has a mechanism for surveillance to identify the transmission of infection and

also address transmission of infections that have been reported by public health

authorities. Ensure there is a process in place for reporting to public health authorities

when the transmission of infections occur.

• Review any water management program documentation, if a water management program

has been implemented, for the hospital risk assessment, and water quality monitoring.

• Review policies and procedures for the detection, investigation and control of outbreaks.