CMS finalizes infection control survey, tells inspectors requirements are 'effective immediately'

March 18th, 2015

The Centers for Medicare & Medicaid Services (CMS) has finalized its long anticipated infection control survey for hospitals, telling its inspectors the requirements are “effective immediately” and can be used to issue citations in visits that are typically unannounced.

Issued Nov. 26, the 49-page survey is similar to the 42-page draft version that has been under review and pilot testing the past two years. With survey finalization, the CMS makes official one of the most important regulatory developments in infection control history. For one thing, the final survey puts IP qualifications, training and certification in CMS regulatory language, giving a boost to the professional aspects of the field. The draft version of the survey generally received favorable reviews for its design and attention to detail by infection preventionists, with some seeing the CMS requirements as a potential game-changer for the field. In addition to specific, citable requirements for infection control, the final version lays the groundwork for ultimately linking hospital survey results directly to CMS reimbursements as a “pay for performance” incentive.

The CMS continues to raise the profile of the infection preventionists, making IPs responsible for taking leading roles in identifying and reducing infection risks to patients and health care workers. By the same token, the CMS survey requires “hospital leadership, including the CEO, Medical Staff, and the Director of Nursing Services [to ensure that] the hospital implements successful corrective [infection control] action plans.” That means the CMS survey should not be perceived as an unfunded mandate, as IPs can use the agency requirements as leverage to sustain and increase program resources to prevent health care associated infections (HAIs). Tens of thousands of hospital patients continue to die of HAIs, including infections that are resistant to nearly all antibiotics.

Indeed, the final CMS survey revises and expands the emphasis on antibiotic stewardship, an area that is a clear target for future regulatory action. Though the antibiotic stewardship requirements cannot be cited under current CMS regulations, their inclusion as an "information" item in the final survey follows a series of critical developments on the issue. For example, President Obama recently issued a sweeping executive order that called for regulations requiring antibiotic stewardship programs and other actions to preserve drug efficacy in the face of rising multidrug resistant pathogens. (See Hospital Infection Control & Prevention , Nov. 2014 issue, cover story.)

The CMS survey requirements for antibiotic stewardship reflect collaboration with the Centers for Disease and Prevention, which has issued similar recommendations and is openly discussing CMS enforcement of the critical issue. The antibiotic stewardship requirements in the final version of the CMS survey include the following:

• The hospital has written policies and procedures whose purpose is to improve antibiotic use (antibiotic stewardship).
• The hospital has designated a leader (e.g., physician, pharmacist, etc.) responsible for program outcomes of antibiotic stewardship activities at the hospital.
• The hospital’s antibiotic stewardship policy and procedures requires practitioners to document in the medical record or during order entry an indication for all antibiotics, in addition to other required elements such as dose and duration.
• The hospital has a formal procedure for all practitioners to review the appropriateness of any antibiotics prescribed after 48 hours from the initial orders (e.g., antibiotic time out).
• The hospital monitors antibiotic use (consumption) at the unit and/or hospital level.

In addition to antibiotic stewardship, the CMS survey calls for inspectors to assess employee health and worker training, hand hygiene, injection safety issues, environmental services, and cleaning and reprocessing equipment. Surveyors also are to document the use of barrier protective equipment and other factors for standard precautions, and contact, droplet and airborne patient isolation measures. The CMS recommends, but does not require, that hospitals begin using the survey as a risk assessment tool to identify infection control problems and areas for improvement.

Editor’s note: Questions and comments about the infection control survey may be submitted to CMS via email to: [email protected]