10 common infection prevention and control deficiency findings in healthcare facilities

Between January and August 2018, Infection Control Consulting Services (ICCS) experienced a record number of facilities reaching out for assistance due to deficiency findings and a need for remediation assistance after accreditation and/or Medicare surveys.

Facilities included ambulatory surgery centers (ASCs), office-based surgery practices, acute-care hospitals, behavioral health hospitals and dental practices.

Here are 10 of the most cited deficiencies across the continuum of care observed by ICCS consultants.

1. Facility is lacking in appointing a designated, qualified professional with training in infection prevention to direct the infection prevention program. This deficiency is most commonly cited in the ambulatory surgery setting. It is not uncommon for facilities to task an existing staff nurse or director of nursing, who is already performing a full-time position's worth of responsibilities, to take on this critical role. Such an appointment often results in challenges with allotting enough time to infection prevention, with facilities often cited for insufficient training and education of the infection prevention designee.

2. Facilities fail to "develop, implement and maintain an ongoing data driven quality assessment and program improvement program." For at least the past two decades, infection prevention has been included in quality and performance improvement programs. Depending on the setting, monthly or quarterly meetings are combined with quality assurance performance improvement (QAPI), but surveyors will expect to see separate agenda items and a separate section in the minutes highlighting activities and data reporting from the infection prevention program. Depending on the size of the facility, services offered and risk prioritization, the expectation is that the program includes at least one infection prevention QAPI project per annum.

3. Compliance monitoring using competencies and various checklists not conducted. This is very frequently cited across the continuum of care. The goals of an infection prevention program include follow-up documentation for compliance and the responsible party. Compliance monitoring is expected for, at a minimum, hand hygiene, infection prevention designee, central processing technician, environment of care (including room turnover) and terminal cleaning in the perioperative environment and cleaning of point of care devices.

4. Failure to produce manufacturer's' instructions for use (IFUs). This deficiency has been cited in almost every survey that ICCS has reviewed as the expectation is that for every product, including basic cleaning products, devices and equipment, either written IFUs from the manufacturer or nationally recognized guidelines and standards be made available throughout the facility for every applicable staff member's use. Many companies provide their "user manuals" online and it is important to refer to guidelines and standards if IFUs are unavailable.

5. Lack of reference to specific "nationally recognized guidelines and standards." Every facility is expected to include a description of the guidelines and standards chosen in their written program. Copies in strategic areas should be available. These guidelines and standards should be printed in a binder or saved on computer for easy access.

6. Reprocessing with a focus on high-level disinfection (HLD) and sterilization in acute and outpatient care, including medical clinics. Reprocessing issues are frequently cited with various deficiencies noted due to facilities not following IFUs or nationally recognized guidelines and standards. Importance of following strict instructions or guidelines cannot be emphasized enough, particularly as central processing deficiencies can lead to immediate jeopardy situations.

7. Reprocessing, with a large emphasis on peel pack items. Double peel packs with the inner pouch folded and a lack of opening the hinged instruments are two of the most commonly cited practices with respect to sterilization. It is no longer common practice to double pack single items to prevent penetration of sharp instruments. Rather, protecting the tips when sharp instruments are opened wide enough using specific tip protector items is in line with standards and IFUs. Some manufacturers of peel packaging include the use of double peel packs, but the IFUs must be followed for optimal sterilization effects.

8. Physical environment deficiencies. These include rust on instruments and equipment, dust on top of equipment and various surfaces, and ripped or torn items such as OR table mattresses and armrests. Rusty instruments in particular are a major problem for surveyors and can result in immediate issues during a survey.

9. Additional physical environment deficiencies. Other common citations include failure to monitor temperature and humidity in the perioperative and central processing areas as well as failure to document these parameters.

10. Safe injection practices. Citations include failure of anesthesia staff to wipe the medication vial's rubber diaphragm and "scrubbing the hub" of the IV line with an alcohol wipe before injecting medications.

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services (ICCS). She has more than 30 years' experience and leads a team of highly skilled infection preventionists who assist ICCS in providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. ICCS focuses on assisting ambulatory surgery centers, hospitals, outpatient clinics, physician offices, dental office and oral surgery practices, nursing homes and other organizations with implementing and maintaining an infection control program that complies with The Joint Commission, AAAHC, Centers for Medicaid & Medicare Services (CMS) and other regulatory agencies. ICCS provides assistance with writing and implementing corrective action plans for deficiencies identified during surveys.

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