§ 485.526 Condition of participation: Infection prevention and control and antibiotic stewardship programs. The REH 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 collaboration with the facility-wide quality assessment and performance improvement (QAPI) program. ( a ) *Standard: Infection prevention and control program organization and policies.* The REH 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 REH and between the REH and other health care settings;
( 3 ) The infection prevention and control program include 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 services furnished by the REH.
( b ) *Standard: Antibiotic stewardship program organization and policies.* The REH 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 REH 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 REH; 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 services furnished by an REH.
( 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 REH's QAPI leadership.
( 2 ) The infection prevention and control professional(s) are 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 REH's QAPI program on infection prevention and control issues.
( iv ) Competency-based training and education of REH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the REH, 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 REH 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 REH's infection prevention and control and QAPI programs, on antibiotic use issues.
( iv ) Competency-based training and education of REH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the REH, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.
( d ) *Standard:Unified and integrated infection prevention and control and antibiotic stewardship programs for multi-facility systems.* If a REH is part of a system consisting of multiple separately certified hospitals, CAHs, and/or REHs using a system governing body that is legally responsible for the conduct of two or more hospitals, CAHs, and/or REHs, the system governing body can elect to have unified and integrated infection prevention and control and antibiotic stewardship programs for all of its member facilities after determining that such a decision is in accordance with all applicable state and local laws. The system governing body is responsible and accountable for ensuring that each of its separately certified REHs meets all of the requirements of this section. Each separately certified REH subject to the system governing body must demonstrate that: ( 1 ) The unified and integrated infection prevention and control and antibiotic stewardship programs are established in a manner that takes into account each member REH's unique circumstances and any significant differences in patient populations and services offered in each REH;
( 2 ) The unified and integrated infection prevention and control and antibiotic stewardship programs establish and implement policies and procedures to ensure that the needs and concerns of each of its separately certified REHs, regardless of practice or location, are given due consideration;
( 3 ) The unified and integrated infection prevention and control and antibiotic stewardship programs have mechanisms in place to ensure that issues localized to particular REHs are duly considered and addressed; and
( 4 ) A qualified individual (or individuals) with expertise in infection prevention and control and in antibiotic stewardship has been designated at the REH as responsible for communicating with the unified infection prevention and control and antibiotic stewardship programs, for implementing and maintaining the policies and procedures governing infection prevention and control and antibiotic stewardship as directed by the unified infection prevention and control and antibiotic stewardship programs, and for providing education and training on the practical applications of infection prevention and control and antibiotic stewardship to REH staff.
( e ) *COVID-19 and seasonal influenza reporting.* Beginning at the conclusion of the COVID-19 Public Health Emergency, as defined in § 400.200 of this chapter, and continuing until April 30, 2024, except when the Secretary specifies an earlier end date for the requirements of this paragraph (e), the REH must electronically report information about COVID-19 and seasonal influenza in a standardized format specified by the Secretary. ( 1 ) Related to COVID-19, to the extent as required by the Secretary, this report must include the following data elements: ( i ) Suspected and confirmed COVID-19 infections among patients and staff.
( ii ) Total COVID-19 deaths among patients and staff.
( iii ) Personal protective equipment and testing supplies.
( iv ) Ventilator use, capacity, and supplies.
( v ) Total patient census and capacity.
( vi ) Staffing shortages.
( vii ) COVID-19 vaccine administration data of patients and staff.
( viii ) Relevant therapeutic inventories or usage, or both.
( 2 ) Related to seasonal influenza, to the extent as required by the Secretary, this report must include the following data elements: ( i ) Confirmed influenza infections among patients and staff.
( ii ) Total influenza deaths among patients and staff.
( iii ) Confirmed co-morbid influenza and COVID-19 infections among patients and staff.
( f ) *Standard: Reporting of data related to viral and bacterial pathogens and infectious diseases of pandemic or epidemic potential.* The REH must electronically report information on acute respiratory illness (including, but not limited to, seasonal influenza virus, influenza-like illness, and severe acute respiratory infection), SARS-CoV-2/COVID-19, and other viral and bacterial pathogens and infectious diseases of pandemic or epidemic potential only when the Secretary has declared a Public Health Emergency (PHE), as defined in § 400.200 of this chapter, directly related to such specific pathogens and infectious diseases. The requirements of this paragraph (f) will be applicable to local, state, regional, or national PHEs as declared by the Secretary. ( 1 ) The REH must electronically report information about the infectious disease pathogen, relevant to the declared PHE, in a standardized format specified by the Secretary. To the extent as required by the Secretary, this report must include, the following: ( i ) Suspected and confirmed infections of the relevant infectious disease pathogen among patients and staff.
( ii ) Total deaths attributed to the relevant infectious disease pathogen among patients and staff.
( iii ) Personal protective equipment and other relevant supplies in the REH.
( iv ) Capacity and supplies in the REH relevant to the immediate and long term treatment of the relevant infectious disease pathogen, such as ventilator and dialysis/continuous renal replacement therapy capacity and supplies.
( v ) Total patient census, capacity, and capability.
( vi ) Staffing shortages.
( vii ) Vaccine administration data of patients and staff for conditions monitored under this section and where a specific vaccine is applicable.
( viii ) Relevant therapeutic inventories or usage, or both.
( ix ) Isolation capacity, including airborne isolation capacity.
( x ) Key co-morbidities or exposure risk factors, or both, of patients being treated for the pathogen or disease of interest in this section that are captured with interoperable data standards and elements.
( 2 ) Unless the Secretary specifies an alternative format by which the REH must report these data elements, the REH must report the applicable infection (confirmed and suspected) and vaccination data in a format that provides person-level information, which must include medical record identifier, race, ethnicity, age, sex, residential county and zip code, and relevant comorbidities for affected patients. Facilities must not report any directly or potentially individually-identifiable information for affected patients (for example, name, social security number) that is not set out in this section or otherwise specified by the Secretary.
( 3 ) The REH must provide the information specified in this paragraph (f) on a daily basis, unless the Secretary specifies a lesser frequency, to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network or other CDC-supported surveillance systems as determined by the Secretary.
( g ) *Standard: COVID-19 vaccination of REH staff.* Until November 4, 2024, unless the Secretary specifies an earlier end date for the requirements of this paragraph (g), the REH must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. ( 1 ) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following REH staff, who provide any care, treatment, or other services for the REH and/or its patients: ( i ) REH employees;
( ii ) Licensed practitioners;
( iii ) Students, trainees, and volunteers; and
( iv ) Individuals who provide care, treatment, or other services for the REH and/or its patients, under contract or by other arrangement.
( 2 ) The policies and procedures of this section do not apply to the following REH staff: ( i ) Staff who exclusively provide telehealth or telemedicine services outside of the REH setting and who do not have any direct contact with patients and other staff specified in paragraph (f)(1) of this section; and
( ii ) Staff who provide support services for the REH that are performed exclusively outside of the REH setting and who do not have any direct contact with patients and other staff specified in paragraph (f)(1) of this section.
( 3 ) The policies and procedures must include, at a minimum, the following components: ( i ) A process for ensuring all staff specified in paragraph (f)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the REH and/or its patients;
( ii ) A process for ensuring that all staff specified in paragraph (f)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
( iii ) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
( iv ) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (f)(1) of this section;
( v ) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
( vi ) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
( vii ) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the REH has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable Federal laws;
( viii ) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws, and for further ensuring that such documentation contains: ( A ) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
( B ) A statement by the authenticating practitioner recommending that the staff member be exempted from the REH's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
( ix ) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
( x ) Contingency plans for staff who are not fully vaccinated for COVID-19.