Accreditation & Regulatory Journal
October 2023

News You Can Use

October’s Compliance Tip of the Month

October’s compliance tip of the month is around the transportation of instrumentation following procedures.
Surveyor’s will cite organizations for not transporting used instrumentation in a manner consistent with the requirements in AAMI ST 58. Specifically, instruments that are transported from one area of the hospital to another through a public hallway in a manner that are either not marked with a biohazard label or other means of identifying the contaminated contents or are not in a leak proof, puncture resistant container.
Transporting instrumentation wrapped in blue paper and/or on a tray and where they are not marked as contaminated or labeled with a biohazard indicator does not meet the intent of the regulation and could pose a risk of physical injury to staff, patients, and visitors and also the possible transmission of infection.
The CMS regulation and the AAMI ST 58 requirements are below for your reference.
CMS
§482.51 Condition of Participation: Surgical Services
§482.51(b) Standard: Delivery of Service
Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. Interpretive Guidelines §482.51(b)
Policies governing surgical care should contain:
  • Aseptic and sterile surveillance and practice, including scrub techniques;
  • Identification of infected and non-infected cases;
  • Housekeeping requirements/procedures;
  • Patient care requirements:
    • Preoperative work-up;
    • Patient consents and releases;
    • Clinical procedures;
    • Safety practices;
    • Patient identification procedures;
  • Duties of scrub and circulating nurse;
  • Safety practices;
  • The requirement to conduct surgical counts in accordance with accepted standards of practice;
  • Scheduling of patients for surgery;
  • Personnel policies unique to the O.R.;
  • Resuscitative techniques;
  • DNR status;
  • Care of surgical specimens;
  • Malignant hyperthermia;
  • Appropriate protocols for all surgical procedures performed. These may be procedure-specific or general in nature and will include a list of equipment, materials, and supplies necessary to properly carry out job assignment;
  • Sterilization and disinfection procedures;
  • Acceptable operating room attire;
  • Handling infections and biomedical/medical waste; and
  • Outpatient surgery post-operative care planning and coordination, and provisions for follow-up care.
Policies and procedures must be written, implemented and enforced. Surgical services’ policies must be in accordance with acceptable standards of medical practice and surgical patient care.
CIHQ encourages organizations to evaluate their programs in order to identify compliance issues and develop and implement a plan to eliminate the potential for a deficiency to be cited during survey.
The following resources are provided to CIHQ accredited organization as well as ARS member to assist with compliance to this regulation:
AAMI ST 58
6.3.4 Containment
Contaminated items should be contained during transport from the point of use to the decontamination area. Containment may be accomplished by any means that adequately prevents personnel contact with the contaminated items during transfer. Transport containers and carts must be marked with a biohazard label or other means of identifying contaminated contents; a red bag or container may also be used to denote that the contents are hazardous. The type of container that should be used depends on the items being transported. Bins with lids, enclosed or covered carts, rigid sterilization container systems, and impermeable bags are among the types of containers that may be used alone or in combination to transport contaminated items. Puncture-resistant, leakproof, closable, and labeled containers must be used for devices with edges or points capable of penetrating skin or the container.
If the manufacturer’s written IFU permit, rigid sterilization container systems with closed valves or intact, dry filters can be used to contain contaminated items for transport with no further coverings, provided that the external surfaces of the container have not been contaminated by blood or other body fluids. Such contamination should be presumed to have occurred if the external surfaces of the container have been touched by persons or items that might have contacted blood or other body fluids. Examples include the scrub person in the OR who is still wearing gown and gloves or the circulating nurse assisting with procedure cleanup who might have donned gloves to handle sponges or specimens and has not removed them before touching the container. If such external contamination is present, the reassembled container system should be further enclosed for transport by placing it in a plastic bag, a bin with a lid, or a closed or covered cart.
Immediately after use, items should be kept moist in the transport container by adding a towel moistened with water (not saline) or a foam, spray, or gel product specifically intended for this use. Transporting contaminated items in liquid should be avoided; if items are soaked in water or an enzymatic solution at the point of use, the liquid should be discarded by properly attired personnel before transport.
Reusable collection containers for holding contaminated items should be made of material that can be effectively decontaminated; containers designated for single use should be made of material that can be incinerated or otherwise disposed of following use. Environmental issues and hazardous waste policies should be considered before single-use containers are selected as a containment method.
Rationale: Materials contaminated with blood or other body fluids can be sources of infection to personnel unless the materials are properly contained. Containment minimizes the possibility of airborne or contact spread of microorganisms. Keeping items moist prevents soil from drying on device surfaces and facilitates the decontamination process. In general, contaminated items should not be transported in liquid because of the risk of spills, the promotion of biofilm formation, and the possibility of employee injury from lifting a heavy container. Some manufacturers instruct users not to use the same rigid sterilization container system for transporting contaminated items as for sterilization, so it is important to consult the manufacturer’s written IFU. If the outer surfaces of the container are touched with gloved, soiled hands, the entire container is considered contaminated.
ARS Resources to Assist with Compliance
#1180 – Tool for Hight Level Disinfection of Supplies & Instruments #1182 – Tool Audit for Sterilization of Supplies & Instruments

CIHQ Accredited Hospital Extranet Site Gets a Facelift

The accreditation division of CIHQ is always working behind the scenes to improve our systems and more importantly our client’s experience. As a result, the hospital’s extranet site has undergone a facelift and will now begin a beta testing period. Once the testing period has been conducted, everyone will be switched over to the new site.
While the look and feel may be a bit different the content and information remain unchanged. Below is a snapshot of what a hospital will see in the current version and then what it will look like in the new version.
New Version
Current Version
So, what is different?
In the new version access to information has been relocated to the blue navigation bar at the top of the page instead of having all the boxes and sections of the site to navigate.
Your online standards and resources are now accessed via the following:
Lists & Archives – Quick Links, Contains Accredited Hospital Listing, Notification Archive, Past Survey Report Archive and ARS Mock Survey Requests
Standards & Resources – Online Standard Manuals, Glossary, Standards Interpretation and Download Standards, Policies & More
Libraries – What’s New on the Website, Resource Library, Reference Library, Regulatory Alert Library and Survey Preparation Library
Education – Webinar Center, Continuing Education Center and Staff Training Library
Application
Partners & Sponsors
The quick links button on the navigation bar under Lists & Archives will provide you with all the resources in a list on the screen and you will be able to enter each one from there if you wish.
What you will see on your extranet landing page is:
  • Important Actions Required. This will still turn red when you have a corrective action plan to enter.
  • Standards, Policies & More – Policies and Survey Tools, Survey Activity Guides and Center of Excellence and Disease Specific Manuals and Information
  • Past Survey Reports – This will contain any survey information for the past 18 months. Any surveys done prior to that they are located under the Lists & Archives under Past Survey Report Archive
  • Miscellaneous Important Notifications – This will contain all notifications posted for the past 90 days. Any notification posted prior to the 90 days can be accessed under Lists & Archives under Notification Archive
There is also a new and improved site directory at the bottom of the screen to help you navigate your extranet page. As always, we welcome your feedback so when you begin to use the new site, please provide us any ideas, suggestions, or comments to Traci at tcurtis@cihq.org.
 

CIHQ Now a CMS Approved Accrediting Organization for Critical Access Hospitals

On May 22, 2023 CMS published the approval of the CIHQ Critical Access Accreditation Program. This was the initial application and is applicable from June 1, 2023 to June 1, 2027. CIHQ is extremely grateful to the facilities that acted as our pilot surveys and to Frio Regional Hospital that graciously allowed us to conduct our observation survey with CMS in attendance. You can find this exciting announcement in the Federal Register at https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services.
We are getting off to a great start with the Critical Access accreditation program. We have accredited Jellico Regional Hospital, Monroe Regional Hospital and Rehoboth McKinley Christian Health Care Services. There are seven that are pending accreditation.

CIHQ Expansion of Accreditation Programs – Update

CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals. The application has been approved and the virtual office review has been completed
  • The final decision to accept the application was published in the Federal Register on May 22, 2023. We are excited about welcoming Acute Psychiatric Hospitals to the CIHQ family of accredited organizations. You can find this exciting announcement in the Register at https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services.
  • Next steps will be the standards and process review. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
    • Griffin Memorial Medical Center
    • SD Human Services Center
    • Adventist Health Vallejo
    • East End Behavioral Health Hospital
    • Glendora Hospital – A College Behavioral Health Hospital
  • A virtual office review was conducted from June 21 – 23, 2023
  • An observation survey was conducted in July. A huge thank you to the State of Oklahoma and Northwest Center for Behavioral Health for volunteering to be our CMS observation survey. We passed with flying colors.
  • Publication in the Federal Register will occur on or by October 19, 2023
Will you be the first acute psychiatric hospital to be accredited by CIHQ? You can open and account and apply today at CIHQ.org click on Acute Psychiatric Hospital and then Apply for Accreditation in the blue navigation bar. Our standards, policies and survey activity guide are available free of charge on the website.

Upcoming Conferences and Sponsorships

2023 Fall Educational Conference & Expo
CIHQ appreciates the work of rehabilitation hospitals, and will be attending AMRPA’s conference October 15-18, 2023 in Dallas. AMRPA hosts an IRF Boot Camp before the conference to provide rehabilitation managers and medical directors with fundamental knowledge.
The conference program will focus on innovative strategies to keep rehabilitation professionals ahead of the curve and providing the highest quality of care, advocacy efforts in the interest of inpatient rehabilitation hospitals and units, outpatient rehabilitation centers, and other rehabilitation providers.