CMS SOM App. A, Tag A-0785

antibiotic stewardship programs for multi-hospital systems.

If a hospital is part of a hospital system consisting of multiple separately certified hospitals

using a system governing body that is legally responsible for the conduct of two or more

hospitals, the system governing body can elect to have unified and integrated infection

prevention and control and antibiotic stewardship programs for all of its member hospitals

after determining that such a decision is in accordance with all applicable State and local

laws. The system governing body is responsible and accountable for ensuring that each of

its separately certified hospitals meets all of the requirements of this section. Each

separately certified hospital subject to the system governing body must demonstrate that:

Interpretive Guidelines §482.42(d)

The hospital must have an infection prevention and control program and an antibiotic stewardship

program for the entire hospital (including all campuses, provider-based locations, satellites, remote

locations, etc.). In the case of a hospital system, it is permissible for the system to have unified and

integrated infection prevention and control and antibiotic stewardship programs (hereafter referred

to as a “unified infection prevention and control and antibiotic stewardship”) for multiple,

separately certified hospitals.

If the hospital uses a unified and integrated program that it shares with other hospitals that are part

of a multi-hospital system, this does not change the requirement that each separately certified

hospital is held responsible and accountable to the system’s governing body for meeting all of the

requirements of an infection prevention and control program and antibiotic stewardship program as

outlined in the regulations at §482.42.

Survey Procedures §482.42(d)

• Surveyors assess the manner and degree of noncompliance with the standards within this

condition to determine whether there is condition-level noncompliance.