Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Just this morning (Wednesday, July 6, 2022), CMS posted QSO-22-20-Hospitals with the same title as this blog.
On September 30, 2019, the Centers for Medicare & Medicaid Services (CMS) published the final rule Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule, which included revisions for the hospital Conditions of Participation (CoP) for 42 CFR §482.42 Infection preventions and control and antibiotic stewardship programs.
The intent of the regulatory revisions was to promote more broad changes and focus in hospitals on surveillance and prevention initiatives to control hospital acquired infections (HAI) and other infectious diseases. The addition of the antibiotic stewardship program requires hospitals to demonstrate efforts, including best practices to follow nationally recognized standards for appropriate antibiotic usage. We recognize that hospitals play a critical role in combatting antimicrobial resistance through implementation of a robust stewardship program. The infection prevention and control program may be viewed separate from the antibiotic stewardship program as these two programs approach the prevention of HAIs and infectious disease from different angles. The regulations allow for flexibility and do not require hospitals to adhere to a specific set of regulatory guidelines or best practices. Lastly, the regulations now allow hospital systems to have unified and integrated infection prevention and control and antibiotic stewardship programs.
Revised requirements include:
• Infection prevention and control program organization and policies
• Antibiotic stewardship program organization and policies
• Leadership responsibilities
• Unified and integrated infection prevention and control and antibiotic stewardship programs for multi-hospital systems
The revisions are found starting on page 3 of this 22-page Memorandum. Look for the red ink.