CMS inspections find infection control lapses in two-thirds of ASCs

By: March 31st, 2010 Email This Post Print This Post

A report from the Fifth Decennial International Conference on Healthcare-Associated Infections indicates that a pilot study of government inspections of ambulatory surgery centers (ASC) found roughly two-thirds of ASCs have infection control deficiencies.

The Centers for Medicare and Medicaid Services (CMS) conducted surveys at 68 ASCs in three states (32 in Maryland, 16 in North Carolina, and 20 in Oklahoma) between June and October of 2008 using the new survey tool created in collaboration with the CDC. This survey worksheet became a routine audit tool for ASC inspections starting in October 2009. 

The pilot study found that 68% of the facilities had at least one lapse in infection control, and 18% had lapses in three or more of the five categories including hand hygiene and use of gloves, injection safety, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

This table indicates that handling of blood glucose monitoring equipment, safe injection practices, and equipment reprocessing were the most common lapses in infection control.

“ASCs are encouraged to review the new audit tool, related requirements, and evidence-based guidelines as part of efforts to ensure adherence to basic infection control and enhance patient safety,” the report concluded.

CMS surveyor Dawn McLane, RN, MSA, CASC, CNOR, will be conducting a detailed review of the CMS audit tool in the April 21st Webcast “Infection Prevention Survey Strategies for ASCs: Comply with CMS’ Conditions for Coverage.” She will be joined by infection prevention program specialist Libby Chinnes, RN, BSN, CIC, who will help participants build a compliant infection prevention program using  evidence-based best practices and current guidelines. Click here for more info or listen to the audio clip below.

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By pam dembski hart on March 31st, 2010 at 11:15 am

This is just the tip of the iceberg. I have surveyed facilities for regulatory complance(bloodborne pathogen and HAZCON and infection control; MD offices and ASC’s) for the past 15 years and have the same or worse statistics regarding serious lapse in infection control. This includes but is NOT limited to inadequate instrument processing. There is NO or poor leadereship and NO or little commitment to the quality of health care delivered. Many of the staff that are responsible for infection control(and dont realize they are) have no formal education nor appropriate training.The basic fundamental of infectious disease prevention is seriously lacking . To add to the seriousness of this issue, is the total lack of oversight by educated informed individuals. This situation is not limited to ASC’s ..and anyone who thinks that is naive. Tthere are as many “minor” surgical procedures (to include endoscopy) that are conducted in physician offices that are totally under the radar screen of CMS, yet they are responsible for contributing to this problem. Wake up and hold healthcare providers accountable to include required training,and mandatory surveys for all facilities.
Pamela Dembski Hart CHSP BS MT ASCP

By Leslie Cottrell on April 6th, 2010 at 5:12 pm

Please continue to offer guidance in helping ASC’s implement the new CMS and AAAHC requirements!!! Leslie

By Evan Sweeney on April 7th, 2010 at 9:55 am

Dawn and Libby Chinnes will provide more detailed guidance in the April 21 Webcast, and you’ll have an opportunity to ask questions…

By Brian Gay on June 23rd, 2010 at 4:06 pm

I am asking the following because from a lay persons view the disinfection of rooms is not complete or effecant. I have been tring for years to educate the health care industry that wiping down areas with a cloth is spreading the problem not solving it.
We have been highly successful in school and college environments at eliminating MRSA, mold,formaldehyde, ammonia and suffied gasses. We have been following the MRSA and C-diff problem in health care centers for some time and can not change anyones idea of disinfection, if you continue to do what you have always done, than your always going to get what you have always gotten.
You need to change your application process, and stop mixing Bleech and water and hoping you don’t harm the patient before you eliminate the virus or bacteria.
Please reply!


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