CMS updates IC interpretive guidelines for hospitals

by A.J. Plunkett (

CMS issued six new survey tags along with other updates to its online manual of interpretive guidelines for Conditions of Participation (COP) on infection prevention and control and antibiotic stewardship programs on Wednesday, July 6.

The long-awaited updates were among the many new requirements from its 2019 final rule burden reduction as well as other rules on discharge planning published just before the start of the COVID-19 pandemic.

While some of the State Operations Manual (SOM), Appendix A, has been updated with those changes, sections under infection prevention and control often just had placeholder language saying “guidance pending.”

The SOM is used by CMS surveyors as guidance for implementing the CoPs. Expect accrediting organizations to match their standards to the requirements—if they haven’t already.

The six new survey tags, A-0760 through A-0765, discuss expectations for antibiotic stewardship programs and policies.

Other tags are updated throughout and all the new updates can be found in Quality, Safety & Oversight Group memo QSO-22-20-Hospitals.

The regulatory revisions outlined in the 2019 final rule were intended, “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,” the memo said.

“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,” said CMS.

“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.”

For more on the changes, see future issues of Inside Accreditation & Quality.

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Accreditation, CMS, Infection Control