REGULATORY REVIEW
CMS Makes Changes to Infection Control Worksheet Learn about the revisions that might have an impact on ASC practices BY SANDRA A. BERRETH
In June, the Centers for Medicare & Medicaid Services (CMS) changed the ASC infection control (IC) worksheet with little
fanfare. It came as a surprise to many, and although most changes might seem minor, they will have an impact on ASC practices.
CMS released a memo to surveyors
[
https://www.cms.gov/Medicare/ Pro vider -Enrollment-and- Certification/SurveyCertification GenInfo/Downloads/Survey-and-Cert- Letter-15-43.pdf], notifying them of “minor revisions to the Infection Control Surveyor Worksheet,” which is used by surveyors in assessing compliance with the infection control requirements set forth in the Conditions for Coverage (CfCs). Revisions are listed below, along with how these changes could be interpreted during upcoming surveys.
Citations without Direct Observation of Problems The instructions for surveying indicate that the various items of the IC work- sheet are to be “assessed primarily by surveyor observation, with interviews used to provide additional confirming evidence of observations.” However, CMS has added new language under Part 2: Infection Control and Related Prac- tices, which indicates that when obser- vation of an actual practice is not avail- able, the surveyor “should attempt to assess the practice by interview or doc- umentation review.” While use of inter- views was included in previous versions of the IC, the new language places more emphasis on the ability of a surveyor to cite a facility for elements of a standard that were not observationally evaluated. Part 2 instructions now state:
“During the survey, observations
or concerns may prompt the surveyor to request and review specific policies and procedures. Surveyors are expected to use their judgment and review only those documents necessary to investi- gate their concern(s) or to validate their observations.” ASCs should ensure that their policies and procedures clearly specify how they are meeting IC work- sheet requirements.
Track the Latest Regulatory and Legislative News for ASCs
Visit ASCA’s web site every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs.
www.ascassociation.org/ GovtAffairsUpdate
24 ASC FOCUS NOVEMBER/DECEMBER 2015
Other Specific Issues Newly Highlighted in the IC Worksheet Use of Artificial Fingernails Under Part I, Hand Hygiene prac- tices to be assessed, CMS has added D: “Personnel providing direct patient care do not wear artificial fingernails and/or extenders when having direct contact with patients.” Although this has been a consideration and a recom- mendation of different infection con- trol organizations, it has not been pre- viously included in the IC worksheet. ASCs should make sure that anyone giving patient care in the surgery cen- ter is not wearing artificial fingernails, whether that individual works directly in the operating room or not. Under Part II, Injection Practices, CMS has added language indicating that “Some types of infection control breaches, including some specific to medication administration practices, pose a risk of blood-borne pathogen transmission that warrant engagement of public health authorities. When management review confirms that a survey has identified evidence of one or more of the breaches described in S&C: 14-36-All, in addition to tak- ing appropriate enforcement action to ensure the deficient Medicare prac- tices are corrected, the SA should also make the responsible State public health authority aware of the identi- fied breach.”
ASCs and their governing bod- ies should be aware that certain infec- tion control breaches deemed the most serious by surveyors will be reported to the state authorities. ASCs should have policies in place to address how to handle these types of infection con- trol breaches.
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