The CMS Hospital Infection Prevention and Control program is a vital initiative for healthcare facilities to ensure patient safety and reduce the spread of infections. In 2023, CMS compliance requirements for this program emphasize the need for hospitals to implement rigorous infection control measures, maintain stringent hygiene standards, and promote antibiotic stewardship to prevent the emergence of antibiotic-resistant strains of bacteria. Hospitals must adhere to these requirements to maintain their CMS certification and provide high-quality, safe patient care. Learning Objectives:- Recall the standard and new interpretive guidelines for infection prevention and control Relate key requirements for an infection prevention and control program Identify the requirements for infection prevention and Antibiotic Stewardship lead Describe what CMS requires for safe injection practices and sharps safety Discuss that CMS has a final infection control worksheet Register, https://conferencepanel.com/conference/the-cms-hospital-infection-prevention-and-control-and-antibiotic-stewardship-program-cms-compliance-requirements-2023

1. CMS Hospital Conditions of
Participation Infection Prevention
and Control and ASP

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Speaker
▪Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ Email questions to CMS:
Critical Access Hospitals: qsog_CAH@cms.hhs.gov.
Acute hospitals: qsog_hospital@cms.hhs.gov.
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3. Infection Control Standards
Deficiencies
Infection Control Interpretive
Guidelines

4. Deficiencies
▪ Failed to have PI on infection control issues
▪ Failed to immunize staff with flu vaccine
▪ Failed to ensure staff had immunity to infectious
diseases
▪ Failed to have an ongoing IC program
▪ Failed to have all the required policies
▪ Failed to enforce hand hygiene guidelines

5. Deficiencies
▪ Not cleaning glucometers between uses
▪ No policy for cleaning nebulizer between uses
▪ Failed to dispose of hazardous waste in the right
container
▪ No log/documentation of processes
▪ Expired medication and equipment
▪ Dirty keyboard
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6. Deficiencies
▪ Housekeeping carts not cleaned after each use
▪ Did not presoak dirty surgical instruments
▪ Did not throw sharps in sharps container
▪ Sharp's container over the line
▪ Not using single dose vials
▪ Using insulin pens inappropriately
▪ Using multidose vials inappropriately plus expired
vials
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7. Infection Prevention &
Control and Antibiotic
Stewardship
CoPs
Infection Control Interpretive

8. What the Programs Must Show
▪ Adherence to nationally recognized infection
prevention and control guidelines
▪ Best practices for improving antibiotic use where
applicable
▪ To reduce development and transmission of HAIs and
antibiotic resistant organisms
▪ Identified prevention and control problems and
antibiotic use issues must go through QAPI
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9. Interpretive Guidelines
▪ Must have an active infection control program
throughout the hospital
▪ For surveillance, prevention and control of HAIs and other
infectious diseases
▪ A program for the optimization of antibiotic use
through stewardship
▪ Program must include a system
▪ Preventing, identifying, reporting, investigating and
controlling infections and communicable diseases for all
▪ For improving antibiotic use for patients
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10. CDC and CMS Interoperability Program*
▪ Addresses electronic reporting for payment
adjustments under IPPS
▪ Most acute hospitals participate
▪ CAHs are eligible
▪ Check with person in charge of quality reporting
▪ Reporting AUR surveillance measure for Electronic
Health Record (EHR) begins January 2024
▪ More information available at:
▪ https://www.cdc.gov/nhsn/cms/cms-faq-aur.html
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11. Documentation 762 & 763
▪ Hospital-wide program documents evidence-based
use of antibiotics in all department and services
(762)
▪ To reduce adverse consequences of inappropriate use
▪ Documents improvements, including sustained
improvement in proper antibiotic use (763)
▪ Must provide documentation of improvements toward
proper use of antibiotics
– To reduce risk of adverse drug events, antibiotic-resistant
infections
▪ Should be updated with any advancements
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12. Joint Commission
Antibiotic Stewardship Program

13. TJC Antibiotic Stewardship Program
▪ Reference only and to assist with CMS regulations
▪ Joint Commission updated the ASP requirements*
▪ Goal: slow the emergence of antibiotic resistance
bacteria and prevent the spread of resistant infections
▪ CDC:
▪ 2.8 million antibiotic-resistant infections annually
▪ Over 35,000 people die as a result
▪ Optimizing antibiotic use plays a critical role
▪ NOTE: no similar requirements in current CoPs but
still require an effective ASP
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