Welcome to the monthly HFAP newsletter for hospitals. Each issue will focus on one or more educational topics relevant to keeping your organization survey-ready. We may highlight a regulatory change or newer standard, take a close look at a frequent deficiency citation, or offer a best practice. We’ll keep this content brief and actionable. If there are specific topics you’d like to see addressed in this way, drop us a note at info@hfap.org. Use “DYK suggestion” in your subject line. We look forward to hearing from you!

Designating Infection Control Leadership

If nothing else, this past year has created a renewed emphasis on issues of infection control. Designation responsibility for a leadership role was part of CMS regulatory updates in 2019 that became effective with the 2020 edition of the HFAP hospital manuals.

HFAP acute care hospital and CAH standards require that one or more individuals be formally designated as the Infection Control Officer (or Officers). The appointment must be based on the recommendations of the medical staff leadership and nursing leadership.

Similarly, hospitals and CAHs must formally designate a person or persons to be responsible for the antibiotic stewardship program. This appointment must be based on recommendations of the medical staff and pharmacy leadership.

A single person may be designated for both roles. To demonstrate compliance, HFAP surveyors will look for:

1. Letters of appointment.
2. A description of the responsibilities of the role. This may be included in the letter of appointment or in a job description.
3. Evidence that the individual is qualified through education, training, or experience.
4. Evidence of a formal appointment approval process.

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