Menu

Long-Term Care

Regulatory Requirements

The Conditions of Participation (CoP) for Center for Medicare and Medicaid Services (CMS) was revised in October 2016 for long-term care facilities (LTCF).  The current regulations require LTCF to develop an Infection Prevention and Control Program (IPCP) that includes an Antimicrobial Stewardship Program (ASP).  The ASP must, at a minimum, includes antibiotic use protocols and a system to monitor antibiotic use.  To view the full updated CoP, visit https://www.gpo.gov/fdsys/pkg/FR-2016-10-04/pdf/2016-23503.pdf.

The interpretive guidance for the new CMS CoP was published on June 30th, 2017.  To view the full document, visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html.  The following are excerpts from the 696-page document relevant to ASP in LTCF.

42 CFR 483.80(a)(3)–pertaining to antibiotic stewardship program

Intent of the regulation is to ensure facility

  • optimizes treatment of infection through use of protocols
  • reduces risk of adverse events from antibiotic use
  • monitors facility-wide antibiotic use

ASP should include leadership support and accountability via the participation of

  • the medical director
  • consulting pharmacist
  • nursing
  • administrative leadership, and
  • individual with designated responsibility for the infection control program if different.

ASP protocols must

  • be incorporated in the infection prevention and control program
  • be reviewed on an annual basis
  • contain a system of reports to monitor antibiotic usage and resistance data
  • incorporate monitoring of antibiotic use
  • assess residents for suspected infection using standardized tools and criteria
  • include mode and frequency of prescribers and nursing education on ASP

Review by surveyor will determine if facility’s ASP includes

  • antibiotic use protocol(s) to address antibiotic prescribing practices such as
    • documentation of indication, dose, duration of antibiotic
    • review of laboratory reports to determine if antibiotic is indicated or needs adjustment
    • use of an infection assessment tool or management algorithm
  • system to monitor antibiotic use such as
    • antibiotic use reports
    • antibiotic resistance reports

Page last reviewed: August 16, 2018