It has been 4 years since full implementation of the infection control regulations and since the agencies were trying to determine how to monitor compliance with these standards. In addition CMS is challenging all surveyors to strengthen their review of these standards. So what are some of the areas where the surveyor is looking? (It should be noted that most centers undergoing a survey feel they are ready for this survey but the reality is there is a continuous need for monitoring staff, physician and anesthesia activity to comply with infection control standards.)
Frequently cited areas:
• Expired medications – If your medications are on the shortage list and you must keep in the cabinet, this must be noted by the medication plus the governing body must be made aware and approve such practices.
• Hand hygiene – Centers should monitor their staff, physicians and anesthesia related to the proper technique of hand hygiene. No center is 100% on this process. We are human. What is important is that we monitor and continue to set a goal for compliance of the team.
• General cleaning of facility – Terminal cleaning, use of proper cleaning supplies, staff and housekeeping knowledge of cleaning and training.
• Expiration of supplies – Always on the list.
To be prepared use the CMS IC tools that can be found on the internet and have it ready for survey - http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf
