Texas ASCS 2013 Annual Meeting
Laura Strohmeyer RN, CGRN, CASC
AmSurg Corp
Dallas, Texas
Objectives
1. Review the CMS regulations on infection
control as they pertain to Ambulatory
Surgery Centers
2. Identify the elements of a comprehensive
ASC Infection Control Plan
3. Discuss how to maintain an ASC Infection
Control Plan
4. Review required TDSHS Infection Control
Reporting
CMS- Centers for Medicare Services
 Implemented new regulations for Ambulatory Centers
effective 5/18/09
 Individual responsible and trained in infection control
 Infection Control Plan and Risk Assessment
 Staff and Physician training
 Center approved national guidelines
 Conducting unannounced surveys to check for
compliance
 Implemented patient tracking to the survey process
Condition 416.51 (Q-240)
The ASC must maintain an infection control program that seeks to
minimize infections and communicable diseases.
1. Standard 416.51a (Q-241) The ASC must provide a functional and sanitary
environment for the provision of surgical services by adhering to professionally
acceptable standards of practice.
2. Standard 416.51b (Q-242) The ASC must maintain an ongoing program
designed to prevent, control, and investigate infections and communicable
diseases. In addition, the infection control and prevention program must
include documentation that the ASC has considered, selected, and implemented
nationally recognized infection control guidelines.
3. Standard 416.51b1 (Q-243) The program is under the direction of a designated
and qualified professional who has training in infection control.
4. Standard 416.51b2 (Q-244) The program is an integral part of the ASC’s
quality assessment and performance improvement program.
5. Standard 416.51b3 (Q-245) Responsible for providing a plan of action for
preventing, identifying and managing infections and communicable diseases
and for immediately implementing corrective and preventative measures that
result in improvement.
Summary of CMS Regulations
 Develop and implement an Infection Control Program
 Ongoing program to prevent, control and investigate
infections and communicable diseases utilizing
nationally recognized infection control guidelines
 Designated professional with training in infection
control
 Part of QAPI Program
 Plan for preventing, identifying and managing
infections
 Provide a sanitary environment
Other Conditions for Coverage
 QAPI
 Physical Environment
 Administration of drugs
 Privacy and Safety
Infection Control Program
 Program Setup
 Infection Control Program
 Nationally Recognized Guidelines, policies and
procedures
 Training
 Infection Control Professional
 Staff training, credentialed staff
 Implementation and Surveillance
 Audit staff competency and compliance
 Track patient/employee infections
Program Setup
 Center Information
 Patient population, types of procedures
 Risk Assessment - Infection Control Issues
 Scope Reprocessing, Surgical Site Infections
 Safe Injection Practices
 Environment cleaning and housekeeping
 Identify Infection Control Professional
 Job description, training, competency
 Board Approval
 Surveillance of patient and employee infections
 Annual goals and evaluation of plan
Nationally Recognized Guidelines
 Association of Perioperative Registered Nurses
(AORN)
 Society of Gastroenterology Nurses and Associates
(SGNA)
 American Society for GI Endoscopy (ASGE)
 Association for Professionals in Infection Control
and Epidemiology (APIC)
 Centers for Disease Control and Prevention (CDC)
 Healthcare Infection Control Practices Advisory
Committee (HICPAC)
Training
Infection Control Professional
 National Society Membership (APIC)
 Conferences
 APIC: Infection Prevention for ASC’s: Meeting CMS Conditions for
Coverage
 Webinars
 Ongoing: Stay informed of updates
 Staff
 Review of infection control policies
 Review of guidelines
 Bulletin Boards, Posters, Staff meetings
 Physicians, anesthesia, contracted staff
 Documentation
A 24-year-old man who had quadriplegia due to a traumatic spinal cord injury was found
on routine surveillance cultures to have methicillin-resistant Staphylococcus aureus (MRSA)
colonization of his anterior nares. He had no history of MRSA infection or colonization. To
assess the potential implications of the patient's MRSA carriage for infection control, an imprint
of a health care worker's ungloved hand was obtained for culture after the worker had
performed an abdominal examination of the patient. The MRSA colonies grown from this
handprint on the plate (CHROMagar Staph aureus), which contained 6 µg of cefoxitin per
milliliter to inhibit methicillin-susceptible S. aureus, are pink and show the outline of the
worker's fingers and thumb (Panel A). With the use of a polymerase-chain-reaction assay, the
mecA gene, which confers methicillin resistance, was amplified from nares and imprint isolates.
After the worker's hand had been cleaned with alcohol foam, another hand imprint was
obtained, and the resulting culture was negative for MRSA (Panel B). These images illustrate the
critical importance of hand hygiene in caring for patients, including those not known to carry
antibiotic-resistant pathogens.
Surveillance- Patients
 Track suspected and reported infections
 Surgical Site Infections, Phlebitis, Diarrhea, Fever
 Monthly patient list to physicians, post-op phone calls
 Infection Control Breech
 Scope reprocessing
 Sterilization
 Infection Control Outbreaks
 Hepatitis, c.difficile, MRSA
Surveillance- Personnel
 Track reported infections
 GI infections
 Flu
 MRSA
 Prevention
 Hepatitis B Immunizations
 TB skin tests
 Flu vaccine- Texas Administrative Code (TAC), Title 25 Health Services,
Part 1, Department of State Health Services, Chapter 1, Texas Board of
Health, will be amended to add new Subchapter Z Adoption of Vaccine
Preventable Disease Policy for hospitals and other facilities licensed
under Subtitle B of Title 4 of the Health and Safety Code, including ASCs
Compliance
 Competencies
 Scope Reprocessing
 Sterilization
 Audits
 Scope Reprocessing
 Sterilization
 Hand Hygiene
 Safe Injection Practices
 Housekeeping performance
ASC Infection
Control Surveyor
Worksheet (Exhibit
351) was revised
4/13 to improve
clarity.
Reporting
 Staff Meetings
 Quality Assurance Performance Improvement
 Infection Control Report
 Infection Control Plan and evaluation
 Infection Control focus studies
 Policies and Procedures
 Infection Control outbreak, concerns
 Governing Board
Documentation
 Infection Control Binder
 Infection Control Plan, Policies
 Infection Control Risk Assessment, Annual goals and
evaluation, Quarterly reports
 Infection Control Coordinator: Job Desc, Competency,
Training
 Nationally Recognized Guidelines
 Surveillance
 Training- Staff, Physicians, CRNA’s
 Audits
Infection Control 4 ⅟₂ years later…
Challenges
 Turnover of the Infection Control Professional
 Infection Control Professional not meeting
expectations
 Minimal ongoing education
 Decrease in audit completion
 Compliance in infection control practices decreases
 Failure to implement infection control policies
 Lack of physician and governing board involvement
Revive your Infection Control Plan
 Continue Infection Control Training for all
 Follow trends in infection control
 Perform frequent audits, get more detailed
 Hold staff accountable
 Enforce policies- (mandatory Flu vaccine)
 Network with other ASC’s
 Governing Board, Administrators involvement
Administrator Involvement
 Ask the Infection Control Professional to explain the
Infection Control Plan and show documentation
 What is the plan, how was it developed?
 What training has been completed this year?
 What audits have been performed this year?
 Did we meet our infection control goals this year?
 What infection control practices have we improved
recently? Review the documentation
 How many possible infections were reported this year?
 Are all the employee and credentialed staff health files
up to date?
 Review quarterly reports
TDSHS Infection
Control Reporting
For Office Use Only:
Notification #:___________________
MOLD REMEDIATION NOTIFICATION FORM
DO NOT WRITE IN THIS BOX- FOR DEPARTMENT USE ONLY
Date Received:___/___/___ Source: ___Fax ___E-mail ___Mail ___Walk-in
SECTION 1: TYPE OF NOTIFICATION
TYPE OF NOTIFICATION: (Select one and fill in the requested information)
ORIGINAL: The DSHS Central Office was notified by:
Date sent: ___/___/___ Time sent: _________________
Fax
a.m.
E-mail
p.m.
Hand Delivery
Mail
AMENDMENT No.____ OR
CANCELLATION
Amendment/Cancellation Notification Required Information:
 Was the Environmental Health Notifications Group (EHNG) notified by phone between 8:00 a.m. and 5:00 p.m. Central
Time of any project date changes or cancellation prior to the original start and/or original stop date?
Yes
No.
 If yes, provide the name of the person you spoke with:
________________________________________________
 Was the original amended notification faxed/e-mailed/overnight-mailed within 24 hours of the phone call? Yes No.
Date: _____/_____/_____ Time: __________ a.m. p.m.
Additional Required Notice for Date Changes Less Than 5 Days from Original Start/Stop Date:
 Was the appropriate Regional Office notified by e-mail/phone between 8:00 a.m. and 5:00 p.m. Central Time of any project
date changes or cancellation prior to the original start and/or original stop date? Yes No
 If yes, provide the name of the person you spoke with: _____________________________________________________
Date: ___/___/___ Time: _____________________ a.m. p.m.
 Was a copy of the amended notification faxed/e-mailed/overnight-mailed to the appropriate Regional Office within 24 hours
of the phone call? Yes No.
 Give a description of the reason for this amendment or cancellation:___________________________________________
___________________________________________________________________________________________________________________________
EMERGENCY
Was emergency request made to the Regional Office or (EHNG) by phone? Yes No
If yes, provide the DSHS reference number:_________________ and name of the person you spoke with:
_____________________________________ Date: ___/___/___ Time: __________ a.m. p.m.
Describe the reason for emergency remediation: ___________________________________________________________
___________________________________________________________________________________________________
(x)
Below if
Amended
AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the left-hand side of form below to
indicate amended information.
FACILITY INFORMATION
1. Facility Location/Description of Area
……. Facility/Residence Name:______________________________________________________________________________
……. Physical Address:____________________________________________________________________________________
……. County:_____________________ City:___________________________________ Zip:__________________________
……. Facility Contact Person: _____________________________________ Phone #: (
)____________________________
……. Description of area/room number:________________________________________________________________________
___________________________________________________________________________________________________
……. Area of mold to be remediated: ______________________________________ Number of floors:_____________________
…….
2. Type of Facility (Select one)
Owner-occupied Residential Dwelling Unit
Other
WORK SCHEDULE/DESCRIPTION OF WORK TO BE CONDUCTED
1. Scheduled dates of mold remediation:
……. Start date: ___/___/___ and Stop date: ___/___/__
……. Work days:
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
……. Working hours: ___________________
a.m.
p.m. to ______________________
a.m.
Sun.
p.m.
2. Description of work to be conducted
……. Description of mold remediation to be conducted:___________________________________________________________
____________________________________________________________________________________________________________________________
Questions?
Laura Strohmeyer RN, CGRN, CASC
Laura Schneider RN, CGRN, CASC
Laura.Schneider@AmSurg.com
214-406-3623