CMS REQUIREMENTS: ESSENTIAL ELEMENTS FOR ASCS Luci Perri, RN, MSN, MPH, CIC, FAPIC Infection Control results OBJECTIVES Identify three areas frequently cited by surveyors State how to avoid two common pitfalls when undergoing a CMS survey 1
STATE OPERATIONS MANUAL 42 CFR 416.51 Infection Control Worksheet FACILITY INFORMATION Gathered beforehand 2
DIRECT OBSERVATION This Photo by Unknown Author is licensed under CC BY-ND EXPLICIT INFECTION CONTROL PROGRAM 3
EXPLICIT INFECTION CONTROL PROGRAM Infection control guidelines LICENSED PROFESSIONAL 4
SURVEILLANCE NOTIFIABLE DISEASE REPORTING Title: POLICY/PROCEDURE NOTIFIABLE DISEASE REPORTING Category: Number: Author: POLICY/PROC EDURE Title: NOTIFIABLE DISEASE REPORTING Infection Prevention and Control Category: Infection Prevention and Control Number: IC.206-2014 Author: Infection Prevention and Control IC.206-2014 Infection Prevention and Control 5
STAFF TRAINING Specific staff Frequency Method Documentation If training is completely absent, then consideration should be given to condition-level citation in relation to 42 CFR 416.51, particularly when the ASC s practices fail to comply with infection control standards of practice. EMPLOYEE HEALTH Immunization status Staff screening for infectious diseases Work restrictions and return to work policy Methods to evaluate exposed staff 6
HAND HYGIENE All personnel Throughout visit Accessibility ALCOHOL BASED HAND RUB CMS EOC Standards 7
MISSED HAND HYGIENE OPPORTUNITIES INJECTION PRACTICES Unless otherwise indicated, a No response to any question...must be cited as a deficient practice in 42 CFR 416.51(a) 8
INJECTION PRACTICES Single use One syringe One needle Medications drawn up Date and time of draw, initials of the person drawing, medication name, strength, time and beyond-use date 9
INJECTON PRACTICES All vials Disinfect rubber septum Clean needle and syringe each time entered 10
MULTIDOSE VIALS Do not draw up in patient care area Single use vials = one patient 11
ONE PATIENT SHARPS CONTAINERS 12
SINGLE USE DEVICES, STERILIZATION, AND HIGH LEVEL DISINFECTION Observations are to be made of staff performing equipment reprocessing (e.g., surgical techs), unless these activities are performed under contract or arrangement off-site from the ASC. Unless otherwise indicated, a No response to any question below must be cited as a deficient practice in relation to 42 CFR 416.51(a). SINGLE-USE DEVICES 13
REPROCESSING SINGLE USE DEVICES Approved by FDA for reprocessing Sent to an FDA reprocessor STERILIZATION Critical equipment is sterilized 14
OSHA BBP (29 CFR 1910.1030 INSTRUMENT TRANSPORT Needlestick Safety and Prevention Act 15
PRECLEANING According to manufacturer s instructions At point of use 16
WORKFLOW FROM DIRTY TO CLEAN AAMI ST79, page 24 ( 2013) PHYSICAL ENVIRONMENT Record temperature daily 68 F and 73 F Decontamination: 60 F and 65 F Humidity 30% and 60% Air pressures Negative for dirty Positive for clean If one room, air should flow from clean to dirty 10 air exchanges per hour Sterile storage Temp and humidity can be higher 17
ENZYMATIC SOAK 18
Test washer AUTOMATIC INSTRUMENT CLEANING 19
CLEAN SIDE Visually inspected before sterilization What is done with rejected (dirty) instruments? PACKAGING MATERIALS MUST MATCH STERILIZER Steam Ethylene oxide Hydrogen peroxide gas plasma Hydrogen peroxide vapor 20
CITATIONS Rigid container filters missing or not changed Tip protectors inappropriat e for type of sterilization Double peel pouch with inner pouch folded over Heavy instrument s damaging seams of peel pouch 21
STERILIZATION 1 Manufacturer s instructions Sterilizer Instruments Packaging materials 2 What to do if those don t match? STERILIZATION MONITORING 01 Chemical 02 Physical 03 Biological 22
CHEMICAL INDICATORS BIOLOGICAL INDICATORS Match to sterilizer and cycles Correct incubator Approved BI 23
DOCUMENTATION Sterilization logs All monitoring must be recorded Maintenance of all equipment Instruments should be traceable to the patient Sterilization label on each item Recall policy STERILE STORAGE After sterilization, medical devices and instruments are stored in a designated clean area so that sterility is not compromised 24
IMMEDIATE USE STEAM STERILIZATION Same decontamination and cleaning as SPD Container approved for IUSS Not routinely performed Aseptic transport and delivery to sterile field ENVIRONMENTAL INFECTION CONTROL Operating rooms are cleaned and disinfected after each surgical or invasive procedure with an EPA-registered disinfectant Regular cleaning in patient care areas ORs between cases and daily terminal cleaning Blood and body fluid spill process Contracted EVS 25
CITATIONS Visible dirt in direct patient care areas Lack of understanding of dwell/wet/kill time for disinfectants Torn mattresses Rusting equipment Damaged/peeling walls, counters, and cabinets PACU CITATIONS Oxygen tubing Oxygen connectors Suction canisters and tubing 26
POINT OF CARE DEVICE DISINFECTION Manufacturer s instructions Multiple patients? ASC policy 27
SURGICAL ATTIRE SURGICAL ATTIRE AORN guidelines ASC Policy Scrubs 28
RESOURCES Toolkit to Improve Safety in Ambulatory Surgery Centers. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/qualitypatient-safety/hais/tools/ambulatory-surgery/index.html For CDC guidelines: https://www.cdc.gov/infectioncontrol/guidelines/index.html Association for the Advancement of Medical Instrumentation: www.aami.org 29
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