New CMS IC requirements are useful for anyone

By: May 27th, 2009 Email This Post Print This Post

As of May 18, 2009 (a little over a week ago), the Centers for Medicare and Medicaid Services (CMS) require that Medicare-certified ambulatory surgery centers meet the 2009 Conditions for Coverage (CfC). Just recently, CMS revised its State Operations Manual (SOM) Appendix L – Guidance for Surveyors: Ambulatory Surgical Centers (ASC), which provides detailed guidance for the conditions, and improvements to the ASC survey process. 

Highlighted in these new CfCs are a number of requirements concerning infection control. Below is a brief overview of the IC-specific conditions:

  • 416.41 Governing Body and Management: Appoint a governing body that is accountable for the quality assessment and performance improvement (QAPI) program.
  • 416.43 Evaluation of Quality: Develop, implement and maintain a QAPI program that focuses on high risk areas that affects health outcomes, patient safety, and quality of care. This also includes implementing data collection methods to ensure improvement over time.
  • 416.51 Infection Control: Maintain an infection control program that intends to minimize infections.

And although these conditions only apply to ASC’s concerned about Medicare reimbursement, the idea of establishing an infection prevention program is pervasive throughout non-hospital, non-accredited settings (particularly after the number of front-page incidents in ambulatory care).

In an interview for recent articles in Medical Environment Update and Briefings on Infection Control, APIC CEO Kathy Warye had this to say about infection control in ambulatory care centers and clinics:

“Ambulatory care has been a considerable concern for us for quite some time because unless the ambulatory care clinic or center is part of a larger healthcare system, there is very little if any infection prevention and control oversight. This is why you have seen the growing number of outbreaks.”

For those concerned specifically with the Medicare’s CFCs,  the Accreditation Association for Ambulatory Health Care (AAAHC) is releasing a new core chapter of standards regarding safety and infection control for accredited organizations. The proposed standards will be available for public comment in August prior to final approval in November, and publication in 2010.

But just because your facility is not Medicare-certified, doesn’t mean there is a free pass to ignore proper infection prevention protocols.  A number of downloads under “Infection Control” in our Tools library will help you assess your program and remedy any weaknesses in smaller facilities simply concerned with quality care rather than regulatory agencies.

 

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