CMS SOM App. A, Tag A-0771

(ii) All HAIs and other infectious diseases identified by the infection prevention and

control program as well as antibiotic use issues identified by the antibiotic stewardship

program are addressed in collaboration with hospital QAPI leadership.

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

Hospitals are required to coordinate internally among all components responsible for infection

control and antibiotic stewardship, including, but not limited to, the infection prevention and

control program, the antibiotic stewardship program, the QAPI program, the medical staff,

nursing services, laboratory services, and pharmacy services.

The hospital’s governing body, the medical staff, and the director of nursing must ensure that the

hospital-wide Quality Assessment and Performance Improvement (QAPI) program and staff in-service training programs address problems identified through the infection prevention and

control program and the antibiotic stewardship program. To reflect the importance of infection

control and antibiotic stewardship, the regulations specifically require that the hospital’s QAPI

and training programs must be involved in addressing problems identified by the infection

control program and antibiotic stewardship program and hold the leadership jointly responsible

for linking the infection control program and antibiotic stewardship program with the QAPI and

training programs. These hospital leaders are also held explicitly responsible for implementing

successful corrective action plans. In order to accomplish this, hospital leaders must monitor

adherence to corrective action plans, as well as assess the effectiveness of actions taken, with

implementation of revised corrective actions as needed.

Education on the principles and practices for preventing infections and the transmission of

infectious agents and the appropriate use of antibiotics within the hospital should be provided to

anyone who has an opportunity for contact with patients or medical equipment or prescribing,

preparing or administering antibiotics, e.g., nursing and medical staff; pharmacy staff,

therapists and technicians, such as those involved in respiratory, physical, and occupational

therapy and radiology and cardiology services; phlebotomists; housekeeping and maintenance

staff; volunteers; and all students and trainees in healthcare professions.

Survey Procedures §482.42(c)(1)(ii)

• Confirm that the hospital’s infection control program and antibiotic stewardship

program are being coordinated with their QAPI leadership, medical staff, nursing

services, and pharmacy services.

• Determine whether the hospital’s QAPI program and staff in-service training programs

address problems identified by the infection control officer(s) and antibiotic stewardship

staff.

• Determine whether infection control and antibiotic use problems identified are reported

to the hospital’s leadership. Verify that hospital leadership takes steps to ensure that

corrective actions are implemented and successful.