CMS SOM App. M, Tag L579

The hospice must follow accepted standards of practice to prevent the transmission

of infections and communicable diseases, including the use of standard precautions.

Interpretive Guidelines §418.60(a)

Accepted standards of practice for health care providers are typically developed by

government agencies, professional organizations and associations. Examples would

include, but not be limited to, the Centers for Disease Control and Prevention (CDC), the

Agency for Healthcare Research and Quality, State Practice Acts, and commonly

accepted health standards established by national organizations, boards, and councils

(e.g., Association for Professionals in Infection Control and Epidemiology (APIC),

American Nurses’ Association etc.)

Standard Precautions are based on the principle that all blood, body fluids, secretions,

excretions (except sweat), non-intact skin, and mucous membranes may contain

transmissible infectious agents. Standard Precautions include a group of infection

prevention practices that apply to all patients, regardless of suspected or confirmed

infection status, in any setting in which healthcare is delivered. These include: hand

hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the

anticipated exposure; and safe injection practices. Also, equipment or items in the patient

environment likely to have been contaminated with infectious body fluids must be

handled in a manner to prevent transmission of infectious agents (e.g., wearing gloves for

direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize

reusable equipment before use on another patient). (Excerpt from CDC “

Guideline for

Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare

Settings 2007.”)

Any deficiency cited as a violation of accepted standards of practice must have a copy of

the applicable standard of practice provided to the hospice along with the statement of

deficiencies. A hospice may also be surveyed for compliance with State practice acts for

each relevant discipline. Any deficiency cited as a violation of a State practice act must

reference the applicable section of the State practice act allegedly violated, and a copy of

that section of the act must be provided to the hospice along with the statement of

deficiencies.