CMS SOM App. M, Tag L577

The hospice must maintain and document an effective infection control program

that protects patients, families, visitors, and hospice personnel by preventing and

controlling infections and communicable diseases.

Interpretive Guidelines §418.60

The hospice infection control program must identify risks for the acquisition and

transmission of infectious agents in all settings where patients reside. There needs to be a

system to communicate with all hospice personnel, patients, families and visitors about

infection prevention and control issues including their role in preventing the spread of

infections and communicable diseases through daily activities.

The hospice’s infection control program may include, but not be limited to the following:

• Educating staff on the science of infectious disease transmission;

• Protocols for addressing patient care issues and prevention of infection related to

infusion therapy, urinary tract care, respiratory tract care, and wound care;

• Guidelines on caring for patients with multi-drug resistant organisms;

• Policies on protecting patients, staff and families from blood borne or airborne

pathogens;

• Monitoring staff for compliance with hospice policies and procedures related to

infection control; and

• Protocols for educating staff and families in standard precautions and the

prevention and control of infection.