CMS SOM App. A, Tag A-0789

and control and in antibiotic stewardship has been designated at the hospital as responsible

for communicating with the unified infection prevention and control and antibiotic

stewardship programs, for implementing and maintaining the policies and procedures

governing infection prevention and control and antibiotic stewardship as directed by the

unified infection prevention and control and antibiotic stewardship programs, and for

providing education and training on the practical applications of infection prevention and

control and antibiotic stewardship to hospital staff.

Interpretive Guidelines §482.42(d)(4)

The hospital must designate an individual or group of individuals with expertise in infection

prevention and control and antibiotic stewardship. This individual or group of individuals are

responsible for communicating, implementing, and maintaining the policies and procedures

governing infection prevention and control and antibiotic stewardship. They are directed by the

unified infection prevention and control and antibiotic stewardship programs. Additionally, they

are responsible for providing education and training on the practical applications of infection

prevention and antibiotic stewardship to hospital staff.

Survey Procedures §482.42(d)(4)

• Review governing body policies for evidence that a qualified individual(s) has/have been

designated as responsible for communicating with the unified infection prevention

program and antibiotic stewardship program, for implementing and maintaining policies

and procedures governing the infection prevention and control and antibiotic

stewardship programs, and training of hospital staff.

• Review documentation that the designated individual(s) communicate(s) with the unified

program leadership related to issues with infection prevention and antibiotic

stewardship.

• Review hospital training documents related to education in infection prevention and

antibiotic stewardship as evidence of training of hospital staff.

• Ram leader develops and implements the hospital-wide antibiotic stewardship program,

based on nationally recognized guidelines, to monitor and improve the use of antibiotics.