CMS Revised Conditions of Participation for ASPs
February 11, 2020
Centers for Medicare & Medicaid Services (CMS) has released a revision for the 2020 Conditions of Participation (COPs) for critical access hospitals (CAHs) that includes requirements for infection prevention (IP)/control and antibiotic stewardship programs (ASP). The Montana Antimicrobial Stewardship (MT ABS) Collaborative has tools and resources to help support CAHs in their IP and ASP program implementations. Access our Antibiotic Stewardship Resources webpage for more information.
The summary below was provided by the Montana Rural Hospital Flexibility Program. Please email Jennifer.Wagner@mtha.org for the entire document, which includes CMS COP updates to Emergency/Hospital Preparedness, Quality Improvement Programs and Care Transitions. More information will be provided on the new COPs during two sessions offered by the Montana Department of Public Health and Human Services (DPHHS) at this year’s MHA Health Summit, March 31 through April 3.
Below is the content from CMS on the requirements for CAHs as they relate to infection prevention/control and antibiotic stewardship programs. These changes are included in the CMS Final Rule: Regulatory Provisions to Promote Program Efficiency, Transparency and Burden Reduction.
485.640 Condition of Participation: Infection Prevention and control and antibiotic stewardship programs.
The CAH must have active facility-wide programs, for the surveillance, prevention and control of healthcare-associated infections (HAIs) and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program (see §485.641).
(a) Standard: Infection prevention and control program organization and policies. The CAH must demonstrate that:
(1) An individual (or individuals), who is qualified through education, training, experience or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership;
(2) The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings;
(3) The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and
(4) The infection prevention and control program reflects the scope and complexity of the CAH services provided.
(b) Standard: Antibiotic stewardship program organization and policies. The CAH must demonstrate that:
(1) An individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body, or responsible individual, as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership;
(2) The facility-wide antibiotic stewardship program:
(i) Demonstrates coordination among all components of the CAH responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services and pharmacy services;
(ii) Documents the evidence-based use of antibiotics in all departments and services of the CAH; and
(iii) Documents any improvements, including sustained improvements, in proper antibiotic use.
(3) The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use; and
(4) The antibiotic stewardship program reflects the scope and complexity of the CAH services provided.
(c) Standard: Leadership responsibilities.
(1) The governing body, or responsible individual, must ensure all of the following:
(i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.
(ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the CAH’s QAPI leadership.
(2) The infection prevention and control professional(s) is responsible for:
(i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines.
(ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities.
(iii) Communication and collaboration with the CAH’s QAPI program on infection prevention and control issues.
(iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures.
(v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by CAH personnel.
(vi) Communication and collaboration with the antibiotic stewardship program.
(3) The leader(s) of the antibiotic stewardship program is responsible for:
(i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.
(ii) All documentation, written or electronic, of antibiotic stewardship program activities.
(iii) Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as the CAH’s infection prevention and control and QAPI programs, on antibiotic use issues.
(iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of antibiotic stewardship guidelines, policies and procedures.
See complete details and other COP changes in the CMS Federal Register – provision to promote program efficiency, transparency and burden reduction.
To see all Montana ASB Collaborative resources, to get information or to find antibiotic stewardship resources access the ABS Collaborative Resources website.
If you have any questions or run into issues with your antimicrobial stewardship program (ASP) implementation and would like help, please use the “Leave a Reply” section below, and we will have one of our subject matter experts get back to you. You can also directly email Patty Kosednar with your questions or comments.
Resource Links:
MT ABS Collaborative Resources Page
CDC Inpatient ASP Website
CDC Outpatient ASP Website
Mountain-Pacific Outpatient ASP webpage
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