CMS SOM App. A, Tag A-0773

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(ii) All documentation, written or electronic, of the infection prevention and control

program and its surveillance, prevention, and control activities.

Interpretive Guidelines §482.42(c)(2)(ii)

The hospital’s infection preventionist(s) and/or infection control professional(s) is responsible

for all documentation, written or electronic, of the prevention and control program, and its

surveillance, prevention, and control activities. ‘‘Documentation’’ encompasses both collecting

and maintaining pertinent information in a systematic fashion.

When considering priority activities, the infection preventionist(s) and/or infection control

professional(s) can review the HHS Action Plan to Prevent Healthcare-Associated Infections

(HHS. ‘‘HHS Action Plan to Prevent Healthcare-Associated Infections. 2025’’)

https://health.gov/hcq/prevent-hai-action-plan.asp.

Survey Procedures §482.42(c)(2)(ii)

• Verify that the hospital’s infection preventionist(s) and/or infection control

professional(s) are documenting, in written or electronic form, the prevention and

control program, and its surveillance, prevention, and control activities.