Objectives 1. Review the CMS regulations on infection control
as they pertain to Ambulatory Surgery Centers 2. Identify the
elements of a comprehensive ASC Infection Control Plan 3. Discuss
how to maintain an ASC Infection Control Plan 4. Review required
TDSHS Infection Control Reporting
Slide 3
CMS- Centers for Medicare Services Implemented new regulations
for Ambulatory Centers effective 5/18/09 Individual responsible and
trained in infection control Infection Control Plan and Risk
Assessment Staff and Physician training Center approved national
guidelines Conducting unannounced surveys to check for compliance
Implemented patient tracking to the survey process
Slide 4
Condition 416.51 (Q-240) The ASC must maintain an infection
control program that seeks to minimize infections and communicable
diseases. 1. Standard 416.51a (Q-241) The ASC must provide a
functional and sanitary environment for the provision of surgical
services by adhering to professionally acceptable standards of
practice. 2. Standard 416.51b (Q-242) The ASC must maintain an
ongoing program designed to prevent, control, and investigate
infections and communicable diseases. In addition, the infection
control and prevention program must include documentation that the
ASC has considered, selected, and implemented nationally recognized
infection control guidelines. 3. Standard 416.51b1 (Q-243) The
program is under the direction of a designated and qualified
professional who has training in infection control. 4. Standard
416.51b2 (Q-244) The program is an integral part of the ASCs
quality assessment and performance improvement program. 5. Standard
416.51b3 (Q-245) Responsible for providing a plan of action for
preventing, identifying and managing infections and communicable
diseases and for immediately implementing corrective and
preventative measures that result in improvement.
Slide 5
Summary of CMS Regulations Develop and implement an Infection
Control Program Ongoing program to prevent, control and investigate
infections and communicable diseases utilizing nationally
recognized infection control guidelines Designated professional
with training in infection control Part of QAPI Program Plan for
preventing, identifying and managing infections Provide a sanitary
environment
Slide 6
Other Conditions for Coverage QAPI Physical Environment
Administration of drugs Privacy and Safety
Slide 7
Infection Control Program Program Setup Infection Control
Program Nationally Recognized Guidelines, policies and procedures
Training Infection Control Professional Staff training,
credentialed staff Implementation and Surveillance Audit staff
competency and compliance Track patient/employee infections
Slide 8
Program Setup Center Information Patient population, types of
procedures Risk Assessment - Infection Control Issues Scope
Reprocessing, Surgical Site Infections Safe Injection Practices
Environment cleaning and housekeeping Identify Infection Control
Professional Job description, training, competency Board Approval
Surveillance of patient and employee infections Annual goals and
evaluation of plan
Slide 9
Nationally Recognized Guidelines Association of Perioperative
Registered Nurses (AORN) Society of Gastroenterology Nurses and
Associates (SGNA) American Society for GI Endoscopy (ASGE)
Association for Professionals in Infection Control and Epidemiology
(APIC) Centers for Disease Control and Prevention (CDC) Healthcare
Infection Control Practices Advisory Committee (HICPAC)
Slide 10
Training Infection Control Professional National Society
Membership (APIC) Conferences APIC: Infection Prevention for ASCs:
Meeting CMS Conditions for Coverage Webinars Ongoing: Stay informed
of updates Staff Review of infection control policies Review of
guidelines Bulletin Boards, Posters, Staff meetings Physicians,
anesthesia, contracted staff Documentation
Slide 11
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Surveillance- Patients Track suspected and reported infections
Surgical Site Infections, Phlebitis, Diarrhea, Fever Monthly
patient list to physicians, post-op phone calls Infection Control
Breech Scope reprocessing Sterilization Infection Control Outbreaks
Hepatitis, c.difficile, MRSA
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Surveillance- Personnel Track reported infections GI infections
Flu MRSA Prevention Hepatitis B Immunizations TB skin tests Flu
vaccine- Texas Administrative Code (TAC), Title 25 Health Services,
Part 1, Department of State Health Services, Chapter 1, Texas Board
of Health, will be amended to add new Subchapter Z Adoption of
Vaccine Preventable Disease Policy for hospitals and other
facilities licensed under Subtitle B of Title 4 of the Health and
Safety Code, including ASCs
ASC Infection Control Surveyor Worksheet (Exhibit 351) was
revised 4/13 to improve clarity.
Slide 19
Reporting Staff Meetings Quality Assurance Performance
Improvement Infection Control Report Infection Control Plan and
evaluation Infection Control focus studies Policies and Procedures
Infection Control outbreak, concerns Governing Board
Slide 20
Documentation Infection Control Binder Infection Control Plan,
Policies Infection Control Risk Assessment, Annual goals and
evaluation, Quarterly reports Infection Control Coordinator: Job
Desc, Competency, Training Nationally Recognized Guidelines
Surveillance Training- Staff, Physicians, CRNAs Audits
Slide 21
Infection Control 4 years later Challenges Turnover of the
Infection Control Professional Infection Control Professional not
meeting expectations Minimal ongoing education Decrease in audit
completion Compliance in infection control practices decreases
Failure to implement infection control policies Lack of physician
and governing board involvement
Slide 22
Revive your Infection Control Plan Continue Infection Control
Training for all Follow trends in infection control Perform
frequent audits, get more detailed Hold staff accountable Enforce
policies- (mandatory Flu vaccine) Network with other ASCs Governing
Board, Administrators involvement
Slide 23
Administrator Involvement Ask the Infection Control
Professional to explain the Infection Control Plan and show
documentation What is the plan, how was it developed? What training
has been completed this year? What audits have been performed this
year? Did we meet our infection control goals this year? What
infection control practices have we improved recently? Review the
documentation How many possible infections were reported this year?
Are all the employee and credentialed staff health files up to
date? Review quarterly reports
Slide 24
TDSHS Infection Control Reporting
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Laura Strohmeyer RN, CGRN, CASC Laura Schneider RN, CGRN, CASC
[email protected] 214-406-3623 Questions?