CMS Infection Control Changes; Up-dates from Excellentia Advisory Group
Important News Updates to CMS Infection Control Audits February 8, 2010

in this issue

From the Desk of Robert Morgan, MSN

Questions & Answers from recent webinars

Environment of care and safety requirements

Criteria of Alcohol-Based Hand Rub Dispensers

Recent questions about reprocessing endoscopes after 5 days of non use comes from the CDC.

STERIS System 1® Processor


 

From the Desk of Robert Morgan, MSN
Robert Morgan in conf room

NEED TO KNOW UPDATES and TIPS:

  • Blood Glucose Monitoring Devices
  • We have previously discussed making sure you are using a device that has been approved for multi patient use. We have checked with both One Touch and Accu-Check. They will send you literature substantiating they are approved if you contact them through their customer service number.
  • Life Safety Code
  • We continue to see citations for Life Safety Code per the survey tool. Check out Part 2 Hand Hygiene Section A b.1 Alcohol based hand rub must be installed per the LSC which can be found at 42 CFR 416.44(b)(5) i.e. minimum horizontal spacing of 4 ft from each other, not installed adjacent to an ignition source among other requirements. If you have allowed your vendors to help you by installing, double check their work!!! A recent citation was given for hand rubs less than 6 inches laterally from an outlet. Beware!!
  • Hand Hygiene
  • The most frequent seen citation in this area appears to be after removing gloves. Staff seem to be unaware this is being required/observed. Please read B under hand hygiene on the survey tool.
  • Infection Control designee
  • It is important to double check with your state regs to see if this person has specific requirements in addition to the training component. Several states do, so do not get caught off guard on this. No doubt states will be upgrading soon so stay tuned!




Greetings!

If you have been attending our Infection Control webinars, you will find this newsletter issue an important addendum to the information that you have already received from us regarding CMS Infection Control Changes and upcoming audits.
It is our pleasure to introduce our new Infection Preventionist Director, Robert Morgan, MSN.
Robert has 30+ years of clinical and management experience within the surgical services and ambulatory surgery industry. He and his staff are now busy assisting facilities to get their programs in place as well as designing corrective action plans when necessary. He will keep you up-dated through this newsletter on the latest information so you can stay current. Please check out our Q&A section. We will continue to post the questions from our ongoing Infection Control webinars there. I am sure some of these same scenarios are pertinent to YOUR facility!!


  • Questions & Answers from recent webinars
  • Our most recent Infection Control webinars had some excellent questions from the audience. Click on the link to see the answers provided by Cathy Montgomery and Robert Morgan to these questions....

    1. What are the follow up requirements for implants?
    2. I am slightly confused regarding the survey. I am unsure if these surveys you are referring to are held at the same time as a standard Medicare survey?
    3. Can you provide me more information or some ideas for the implant log sheet that you spoke of in the webinar?
    4. Are surveyors still requiring TB testing of staff in Low Risk Facilities?
    5. Following an infected case and terminal cleaning of the room, is there a specific wait time until the room can be used again?
    6. What are the directives regarding 30 gm tubes of abx ointments, tubs of silvadene ointment & multi- usage?
    7. What are the CMS directives about insulin? Vaccines?
    8. We are an Endoscopy Center certified as an ASC. What is the ruling on artificial fingernails for nurses?
    9. Does the 28-day expiration on meds include all meds or just injectables?
    10. And others!

    Click for Q&A...
  • Environment of care and safety requirements
  • Operating Room Humidity Ranges Update
    Life Safety surveys last August have given recent attention to ambulatory surgery centers in California requiring that facilities maintain a relative humidity in the O.R.s of >35%. This has prompted notice that we all need to be aware of.

    Click for story and End of Day Cleaning Report Form
  • Criteria of Alcohol-Based Hand Rub Dispensers
  • This is an article distributed by ASHE....While CMS and The Joint Commission are both permitting the installation of alcohol-based hand-rubs (ABHR) in egress corridors of healthcare facilities in accordance with NFPAs Life Safety Code®, there have been numerous questions raised about the placement of the dispensers near electrical outlets and switches. This alert specifically relates to clarification of the term adjacent when placing dispensers near these electrical devices.

    Read on...
  • Recent questions about reprocessing endoscopes after 5 days of non use comes from the CDC.
  • Please refer to page 16 of the 158 paged document for the reference of "Reprocessing endoscopes" and the "Five Day" recommendation per AORN.

    Click for the partial exert of the Guidelines ...
  • STERIS System 1® Processor
  • Steris System1 Processer

    STERIS has issued a letter to its customers explaining the recent FDA update. Steris states, "We want to take this opportunity to update you on SYSTEM 1® matters. On February 2, 2010, the FDA updated its December 10, 2009 information by extending to 18 months the total recommended time period for transitioning from SYSTEM 1 to acceptable alternative devices."

    Read on...
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