Regulatory Update - Infection Control Breaches Warrant Referral to Public Health Authorities

Note: The following regulatory updates are by Kirk Huslage, RN, BSN, MSPH, CIC

On May 30, 2014, CMS released a Survey and Certification Group memo reiterating the need for State Survey Agencies (SAs) or Accrediting Organizations (AOs) to report any identified breaches of generally accepted infection control standards as it relates to safe injection practices (see examples below) to the appropriate state public health authority (i.e., the State’s HAI Prevent Coordinator or Epidemiologist).

• Using the same needle for more than one individual;
• Using the same (prefilled/manufactured/insulin or any other) syringe, pen or injection device for more than one individual;
• Reusing a needle or syringe that has already been used to administer medication to an individual to subsequently enter a medication container (e.g., bag, vial) and then using contents from that medication container on another individual;
• Using the same lancing/fingerstick device for more than one individual, even if lancet is changed.

Other breaches may also be reported at the discretion of the SAs or AOs if they believe that they require a public health assessment and management.  

The full memo can be viewed and downloaded via this link: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-36.pdf