CMS SOM App. A, Tag A-0770

(1) The governing body must ensure all of the following:

(i) Systems are in place and operational for the tracking of all infection surveillance,

prevention, and control, and antibiotic use activities, in order to demonstrate the

implementation, success, and sustainability of such activities.

Interpretive Guidelines §482.42(c)(1)(i)

The hospital’s governing body must ensure that an infection prevention and control program is

in place and operational for the monitoring and prevention of healthcare-associated infections

and the transmission of pathogens, and an antibiotic stewardship program is in place and

operational for the monitoring and improvement of antibiotic use. The development and

implementation of both the infection control and antibiotic stewardship programs should include

leadership support and accountability via the participation of the medical director, pharmacy

director, nursing and administrative leadership, and individuals with designated responsibility

for the infection control program and the antibiotic stewardship program; however the

governing body or responsible individual is responsible to demonstrate the implementation,

success, and sustainability of such activities.

Hospital policies should address the roles and responsibilities for infection prevention and

control within the hospital; how the various hospital committees and departments interface with

the infection prevention and control program; how to prevent infectious/communicable diseases;

and how to report infectious/communicable diseases to the infection prevention and control

program.

Likewise, hospital policies should address the roles and responsibilities for antibiotic

stewardship within the hospital; how the various hospital committees and departments interface

with the antibiotic stewardship program; and how to monitor and improve antibiotic use.

Survey Procedures §485.640(c)(1)(i)

• Review the hospital policies and governing body meeting minutes for a record of support

for the infection control and antibiotic stewardship programs.

• Verify that the hospital policies are being followed for the tracking of all infection

surveillance, prevention and control, and the monitoring of hospital antibiotic use

activities.