14. Infection Control

(Rev. 56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
§416.51 Condition for Coverage – Infection control
The ASC must maintain an infection control program that seeks to minimize infections and communicable diseases.
Interpretive Guidelines: §416.51
This regulation requires the ASC to maintain an active program for the minimization of infections and communicable diseases. The National Institute of Allergy and Infectious Diseases (NIAID) defines an infectious disease as a change from a state of health to a state in which part or all of a host’s body cannot function normally because of the presence of an infectious agent or its product. An infectious agent is defined by the NIAID as a living or quasi-living organism or particle that causes an infectious disease, and includes bacteria, viruses, fungi, protozoa, helminthes, and prions. NIAID defines a communicable disease as a disease associated with an agent that can be transmitted from one host to another. (See NIAID website glossary)
The ASC’s infection control program must:
• Provide a functional and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases
• Be based on nationally recognized infection control guidelines
• Be directed by a designated health care professional with training in infection control
• Be integrated into the ASC’s QAPI program
• Be ongoing
• Include actions to prevent, identify and manage infections and communicable diseases; and
• Include a mechanism to immediately implement corrective actions and preventive measures that improve the control of infection within the ASC.
The ambulatory care setting, such as an ASC, presents unique challenges for infection control, because: patients remain in common areas, often for prolonged periods of time; surgical prep, recovery rooms and ORs are turned around quickly; patients with infections/communicable diseases may not be identified; and there is a risk of infection at the surgical site. Furthermore, due to the short period of time patients are in an ASC, the follow-up process to identify infections associated with the ASC requires gathering information after the patient’s discharge rather than directly. It is essential that ASCs have a comprehensive and effective infection control program, because the consequences of poor infection control can be very serious. In recent years, for example, poor infection control practices related to injections of medications, saline or other infusates in some ASCs have resulted in the transmission of communicable diseases, such as hepatitis C, from one patient infected with the disease prior to his/her ASC visit to other ASC patients, and a requirement to notify thousands of other ASC patients of their potential exposure.
Survey Procedures: §416.51
One surveyor is responsible for completion of the Infection Control Surveyor Worksheet, Exhibit 351, which is used to facilitate assessment of compliance with this Condition.
However, each member of the survey team, as he or she conducts his/her survey assignments, should assess the ASC’s compliance with the Infection Control regulatory requirements.
Made with help of Dr.Explain
Made in Dr.Explain & hosted by TiWri