The following is written by Carla Daley, director of clinical operations for Regent Surgical Health.
At Regent, we believe in "walking the walk," meaning that our facilities should be status accreditation survey ready at all times. In 2009, the Centers for Medicare & Medicaid Services (CMS) updated their Conditions for Coverage (CfC's) with an increased focus on surgical site infections. Ambulatory surgery centers are now required to have an explicit infection control program. If the ASC cannot show that there is a well defined infection control program, a condition-level deficiency must be cited (42 CFR 416.51). Therefore a policy outlining the facilities infection control program is a must!
To help centers gauge whether their new program is in compliance, CMS has provided an infection control surveyor worksheet. Here are just a few of the key elements that are a vital part your infection control program:
• Standard 42 CFR 416.51(b) - Does your ASC's infection control program follow nationally recognized infection control guidelines? These nationally recognized guidelines must be stated in your infection control plan. A few of the recognized guidelines include those from the Centers for Disease Control (CDC), The Association for Professionals in Infection Control and Epidemiology (APIC) and The Association of periOperative Registered Nurses Perioperative Standards and Recommended Practices (AORN). Remember that your infection control practices must reflect whichever nationally recognized guideline you put in your policy. Sounds simple, but when you carefully read the guidelines it is anything but simple, as there are many details and recommendations to follow and keep up with.
• Standard 42 CFR 416.51 - Does your ASC have a licensed health care professional qualified, through training in infection control, and designated to direct the ASC's infection control program? This person does not have to be certified in infection control, but you must have a policy that shows what the education and training requirements are for the designated person. Excellent resources for training include APIC and AORN. In addition to education and training requirements, your infection control policy must also state how much infection control education will be provided for both the designated infection control professional and the facility staff members. Your facilities documentation must show proof of all infection control training.
• Standard 42 CFR 416.51(b)(3) - Does your ASC have a system to actively identify infections that may have been related to procedures performed in the facility? Can you provide documentation on that process? Click here (pdf)to see examples of this documentation.
• Standard 42 CFR 416.44(a)(3) - Does your ASC have a policy/procedure in place to comply with State notifiable disease reporting requirements? Do you have a copy of your state's reportable diseases with your policy? You can download a copy of your state's reportable diseases by visiting the state department of health website for your area.
These key elements listed above are only a portion of what is required in order to be compliant with the CMS infection Control standards, and they are a foundation to a solid infection control program. Regent Surgical Health is dedicated to providing our facilities with the most up-to-date information on infection control. Regent works hand in hand with each facility to ensure that infection control best practice and all other compliance standards are met.
Learn more about Regent Surgical Health.
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