Wyoming Infection Prevention

4th Annual Infection Prevention ConferenceCasper, WY

Russ Forney, PhD, MT(ASCP)Healthcare Survey & Licensing

Aging Division, WY Dept of Health

Good morning, we are here to survey your facility...

Your Survey just started...

• Improved compliance- CONGRATULATIONS• Decrease in condition-level findings• Plan of corrections effectively implemented• Complex problems require ALL STAFF to solve

(infection control, medication, assessments)• Surveillance activities cited less often

Survey Summary (2012-2013)

WYOMING (N=19) REGION 8 (N=271) NATION (N=2164)

Type Description % Surveys Tag Description % Surveys Tag Description % Surveys

LTCASCACHCAH

Infection Control Program

56%

ACHLTCASCCAH

Infection Control Program

40%ACHASCLTC

Medications 38%

ASCACHCAH

Infection Control (Safe, Sanitary Environment,

Surgical Services)

33%

LTCASCACHCAH

Medications 35%

ASCLTCACHCAH

Infection Control Program

33%

LTCASCACH

Patient RightsResident Rights

32%

ASCLTCACHCAH

Infection Control (Safe, Sanitary Environment,

Surgical Services)

35%

ASCLTCFACHCAH

Infection Control (Safe, Sanitary Environment,

Surgical Services)

28%

LTCASCACHCAH

Medications 32%

ASCLTCACHCAH

Infection Control (Condition)

22%LTCASCACH

Patient RightsResident Rights

20%

LTCASCACHCAH

Infection Control (Condition)

12%ASCLTC

Admission & Assessment

18%ASCLTCACH

Advanced Directives, Consents

17%

• Sources of evidence– Observation– Interview– Document review

• Evaluation of findings• Determine if non-compliance exist• Intra-office QA process

Survey Process

• Infection control: A747 (ACH), C278 (CAH), Q240 (ASC)

• Surgical services A940 (ACH), C320 (CAH), Q060 (ASC)

• F441: Infection control (LTC)• Q181: Medication administration (ASC)

Frequent Findings (2012-2013)

Acute Care and Long-Term Care

• Surveillance activities• Sterile processing• High-level & environmental disinfection• Terminal OR cleaning• Sterile (controlled) storage & tracking• It is more difficult (complex processes) to

reprocess an endoscope than it is to use it

Infection Control: Acute Care

“Outside” specialties

• Surveillance activities: outcome & process• Data collection: active & passive• Environmental tour• Hand hygiene• Monitor all areas within the facility• Long-term care is a challenging infection

control setting - it is hard work!

Infection Control: LTC

• Infection control is a never-ending story, ongoing training for surveyors

• Increasing complexity in the survey process for all facilities, notably ACH (PSI program)

• Adding surveyors to the LTC team: formal training and OJT on site (survey)

HLS: The Next Generation

• Online IC database• Network• Annual IC conference• IP manual (2014)• Other facilities, QIO,

associations, WDH, regional affiliations (VA, ESRD, QIO)

Valuable Resources

Is he done yet?

Questions?

Russ Forney, PhD, Healthcare/CLIA surveyorruss.forney@wyo.gov307-777-7123Healthcare Licensing & SurveysAging DivisionWyoming Department of Health

Contact Information