Infection Prevention and Control and ASP: 2026 CMS Compliance Requirements (W6007)-Infection Prevention and Control and ASP 2026 Presentation

Infection Prevention and Control and ASP 2026 Presentation

Pdf Summary

This 2026 webinar document summarizes CMS Hospital Conditions of Participation (CoPs) for Infection Prevention and Control (IPC) and Antibiotic Stewardship Programs (ASP) for acute hospitals (Appendix A) and Critical Access Hospitals (Appendix W). It highlights common survey deficiencies such as weak performance improvement involvement, lack of required policies, poor hand hygiene enforcement, improper device cleaning (e.g., glucometers/nebulizers), unsafe sharps and injection practices, expired supplies, and inadequate documentation.<br /><br />For IPC (Tags A0747–A0751), CMS requires an active, hospital-wide program that conducts surveillance, prevention, and control of healthcare-associated infections (HAIs) and communicable diseases, aligned with nationally recognized standards and integrated with QAPI. Hospitals must designate qualified infection preventionist(s), appointed by the governing body with medical and nursing leadership input, and provide adequate resources based on census, patient risk, and service complexity. Policies must address transmission within the hospital and across care settings, including tracking community- and hospital-onset CDI and MRSA. The program must maintain a clean/sanitary environment across all departments and off-site locations, include outbreak response processes, and address public health authority notifications. Water management policies to reduce Legionella and other opportunistic pathogens are emphasized, including risk assessment, testing protocols, and corrective-action documentation. CMS also requires ongoing electronic reporting of respiratory infection data (COVID-19, influenza, RSV) through NHSN, with options for daily values or weekly totals under certain conditions.<br /><br />For ASP (Tags A0760–A0781), hospitals must appoint qualified stewardship leadership (ideally physician/pharmacist), develop evidence-based antibiotic-use policies, coordinate with IPC/QAPI and clinical services, document improvements and sustained outcomes, adhere to CDC Core Elements and other national best practices, and provide competency-based training.<br /><br />The document also addresses unified/integrated IPC/ASP programs for multi-hospital systems (Tags A0785–A0789), CMS memos on compounding vendors and infection-control breaches, and CDC/FDA guidance on reprocessing reusable medical devices, auditing, and staff competency training.

Keywords

CMS Conditions of Participation

Infection Prevention and Control (IPC)

Antibiotic Stewardship Program (ASP)

Hospital survey deficiencies

Healthcare-associated infections (HAIs) surveillance

QAPI integration

NHSN respiratory reporting (COVID-19 influenza RSV)

Water management plan Legionella

Device reprocessing and cleaning (glucometers nebulizers)

CDC Core Elements antibiotic stewardship