CMS SOM App. M, Tag L833

The hospice must maintain an infection control program that protects patients, staff

and others by preventing and controlling infections and communicable disease as

stipulated in §418.60.

Interpretive Guidelines §418.110(j)

The hospice inpatient facility must have an active surveillance program that includes

specific measures for prevention, early detection, control, education, and investigation of

infections and communicable diseases in the hospice. There must be a mechanism to

evaluate the effectiveness of the program(s) and take corrective action when necessary.

The program must include implementation of nationally recognized systems of infection

control guidelines to avoid sources and transmission of infections and communicable

diseases (e.g., the CDC’s Healthcare Infection Control Guidelines, the CDC Guidelines

for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings,

OSHA regulations, and APIC guidelines on infection control, etc.).

The active infection control program should have policies that address the following:

• Definition of nosocomial infections and communicable diseases;

• Measures for identifying, investigating, and reporting nosocomial infections and

communicable diseases;

• Measures for assessing and identifying patients and health care workers, including

hospice personnel, contract staff (e.g., agency nurses, housekeeping staff) and

volunteers, at risk for infections and communicable diseases;

• Measures for the prevention of infections;

• Measures for prevention of communicable disease outbreaks, such as airborne

diseases (TB, SARS, etc.), food borne diseases (Hepatitis A, Salmonella, etc.),

blood borne diseases (HIV, Hepatitis B, etc.), and others (VRE, MRSA,

pseudomonas, etc.);

• Provision of a safe environment consistent with nationally recognized infection

control precautions, such as the current CDC recommendations for the identified

infection and/or communicable disease;

• Isolation procedures and requirements for infected or immunosuppressed patients;

• Use and techniques for standard precautions;

• Education of patients, family members and caregivers about infections and

communicable diseases;

• Techniques for hand washing, respiratory protections, asepsis as well as other

means for limiting the spread of contagion;

• Orientation of all new hospice personnel to infections, communicable diseases,

and to the infection control program;

• Measures for the screening and evaluation of health care workers, including all

hospice staff, contract workers (e.g., agency nurses, housekeeping staff, etc.), and

volunteers, for communicable diseases, and for the evaluation of staff and

volunteers exposed to patients with non-treated communicable diseases; and

• Employee health policies regarding infectious diseases and when infected or ill

employees, including contract workers and volunteers, must not render patient

care and/or must not report to work.