Hand Hygiene Policies That Will Pass a Medicare CoP Survey (42 CFR § 482.42(b))

Hand hygiene is one of the most fundamental practices in infection prevention, yet it remains one of the most common reasons Medicare-participating hospitals receive deficiency citations during Conditions of Participation (CoPs) surveys. Under 42 CFR § 482.42(a), hospitals must maintain an active infection prevention and control program, which includes written hand hygiene policies consistent with nationally recognized guidelines. Surveyors routinely assess whether these policies are clearly documented, properly implemented, and consistently followed by staff.

For hospitals and hospital-based outpatient departments, hand hygiene compliance is not optional. Failure to meet regulatory expectations can result in citations that place Medicare participation at risk. This article outlines how hospitals can structure hand hygiene policies to align with CoP requirements and withstand regulatory scrutiny.

Understanding the Regulation (42 CFR § 482.42)

Infection Prevention Program Requirements

Under 42 CFR § 482.42(a), hospitals are required to establish and maintain an infection prevention and control program designed to prevent, control, and investigate infections and communicable diseases. Hand hygiene policies are a core component of this program.

Specifically, the regulation requires that hospitals:

• Develop written infection prevention policies and procedures

• Base those policies on nationally recognized guidelines

• Implement practices that reduce the transmission of infections

• Evaluate and update policies as conditions change

Leadership and Oversight Responsibilities

Under 42 CFR § 482.42(c), the hospital must designate qualified personnel responsible for overseeing infection prevention activities. These responsibilities include:

• Developing and implementing infection control policies

• Ensuring staff education and competency validation

• Monitoring compliance with infection prevention practices

• Taking corrective action when deficiencies are identified

Surveyors expect hospitals to demonstrate that hand hygiene policies are not only written, but actively enforced and monitored.

During a Medicare survey, CMS surveyors typically assess the following elements related to hand hygiene compliance:

• Written hand hygiene policies aligned with CDC or WHO guidance

• Evidence of staff training and competency validation

• Observation of staff hand hygiene practices

• Documentation of audits and corrective actions

Table 1: Common Survey Focus Areas for Hand Hygiene

Common Hand Hygiene Compliance Pitfalls

Even hospitals with written policies may receive citations due to gaps in implementation. Common issues include:

• Policies that reference guidelines but lack specific procedures

• Inconsistent staff training or undocumented competencies

• Failure to monitor compliance on a routine basis

• Lack of documented corrective action following identified lapses

Surveyors often cite deficiencies when hospitals cannot demonstrate that policies are actively enforced across all departments.

Checklist: Core Elements of a Compliant Hand Hygiene Policy

A compliant hand hygiene policy should include the following elements:

• Clear definitions of when hand hygiene is required

• Approved hand hygiene methods (soap and water vs. alcohol-based rubs)

• Required actions before and after patient contact

• Expectations for glove use and hand hygiene

• Procedures for monitoring and reporting compliance

Policies should be reviewed periodically and updated to reflect current evidence-based guidance.

Written policies alone are insufficient. Hospitals must demonstrate consistent implementation and oversight.

Step-by-Step Compliance Monitoring Process

1. Train all clinical and non-clinical staff on hand hygiene expectations

2. Validate staff competency during orientation and annually thereafter

3. Conduct routine hand hygiene audits using standardized tools

4. Document audit results and identify trends

5. Implement corrective actions when noncompliance is identified

6. Re-educate staff as necessary and reassess compliance

Under 42 CFR § 482.42(c)(2)(iv)–(v), hospitals are expected to document both training and monitoring activities.

During a routine Medicare survey, a hospital outpatient department was cited for inconsistent hand hygiene practices observed among staff. Although the facility had a written policy, surveyors noted a lack of documented audits and no evidence of corrective action following observed noncompliance.

The citation was issued under 42 CFR § 482.42(a) and § 482.42(c), reflecting deficiencies in both policy implementation and oversight. The hospital was required to submit a plan of correction outlining how hand hygiene compliance would be monitored and enforced going forward.

Sustainable compliance depends on more than policies and audits. Hospitals that perform well during surveys typically embed hand hygiene expectations into their organizational culture.

This includes:

• Leadership reinforcement of infection prevention priorities

• Clear accountability at all staff levels

• Regular communication of compliance expectations

• Transparent reporting of audit results

A culture that prioritizes hand hygiene supports both regulatory compliance and patient safety.

Hand hygiene policies are a cornerstone of infection prevention and Medicare CoP compliance for hospitals. Under 42 CFR § 482.42(a) and § 482.42(c), facilities must not only establish evidence-based policies but also ensure staff training, monitoring, and corrective action processes are in place.

Hospitals that maintain clear documentation, conduct routine audits, and demonstrate active oversight are better positioned to pass surveys and avoid citations.

To further strengthen your compliance posture, consider using a compliance regulatory tool. These platforms help track and manage requirements, provide ongoing risk assessments, and keep you audit-ready by identifying vulnerabilities before they become liabilities, demonstrating a proactive approach to regulators, payers, and patients alike.

1. 42 CFR § 482.42 – Condition of Participation: Infection Control

2. CDC Guideline for Hand Hygiene in Healthcare Settings

3. WHO Guidelines on Hand Hygiene in Health Care