Gayle Lowe, RN, AAAHC surveyor, identifies a challenging area for ASC compliance with accreditation standards and Medicare requirements and offers a best practice to help surgery centers become compliant.
Gayle Lowe: One area where most ASCs are not compliant is with manufacturers' recommendations on diluting the cleaning enzymes for scopes. They're not using accurate measurements.
Use a measuring cup since everyone pumps differently. You see people just pumping the enzyme and pouring in some water. They can put a line in the sink as a pre-measurement and use the line when they put in the required amount of water so you're not arbitrarily filling it to the wrong level for dilution.
They're not following the manufacturers mixing recommendations so they get cited for that by CMS and AAAHC. AAAHC is looking for ASCs to follow manufactures recommendations for high level disinfections on the primary cleaning of scopes.
Learn more about AAAHC.
Read more guidance for meeting accreditation requirements:
- How Long Does an ASC Need to Keep Drug Recall Notices
- 3 QAPI Studies Praised by Surveyors at ASC Durango in Colorado