CMS to Surveyors: Certain Infection Control Breaches Warrant Referral to Authorities
June 9, 2014 02:07 PM
The Centers for Medicare & Medicaid Services (CMS) recently issued a Memorandum (Infection Control Breaches Which Warrant Referral to Public Health Authorities) to State Survey Agency (SA) Directors outlining specific infection control breaches that, when identified by either state surveyors or accrediting organization (AO) surveyors, should be referred to state authorities for public health assessment and management. The instructions outlined in the Memorandum are effective immediately. Certain infection control breaches pose a risk of bloodborne pathogen transmission and warrant referral to public health authorities in order that appropriate risk assessment and - when necessary - patient notification can be conducted.
These are outside the authority of CMS, and the agency is therefore providing guidance to SAs and AOs on appropriate steps that must be taken to correct the deficient practices and ensure that responsible state authorities are notified. The memo directs SAs to consult with their state’s Healthcare Associated Infections (HAI) Prevention Coordinator or State Epidemiologist to identify the preferred referral process for such breaches. AOs are expected to refer such breaches to the appropriate state public health contact.
Breaches to be Referred: When one or more of the following infection control breaches is identified during any survey of a Medicare and/or Medicaid-certified provider/supplier, the SA or AO should make the appropriate State public health authority aware of the deficient practice:
Using the same needle for more than one individual;
Using the same (pre-filled/manufactured/insulin or any other) syringe, pen or injection device for more than one individual;
Re-using a needle or syringe which has already been used to administer medication to an individual to subsequently enter a medication container (e.g., vial, bag), and then using contents from that medication container for another individual;
Using the same lancing/fingerstick device for more than one individual, even if the lancet is changed.
SAs may refer other infection control breaches in addition to those described above if recommended by their state public health authorities. AOs also have the discretion to refer additional breaches they believe require public health assessment and management.