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).

CMS - Relative Humidity (RH): Waiver of Life Safety Code (LSC) Requirements for Anesthetizing Locations

On April 19, 2013 CMS Center for Clinical Standards and Quality Survey and Certification group released S&C Letter 13-25-LSC and ASC.   The topic of this letter was CMS issuing a categorical waiver to allow relative humidity (RH) of ≥ 20 percent in anesthetizing locations.  The summary is a follows:

• RH of ≥ 20 percent permitted in anesthetizing locations:  CMS is issuing a categorical Life Safety Code (LSC) waiver permitting new and existing ventilation systems supplying hospital and critical access hospitals (CAH) anesthetizing locations to operate with a RH of ≥ 20 percent, instead of ≥ 35 percent.  CMS is also recommending that RH not exceed 60 percent in these locations.

Fiscal Year 2014 CMS Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) Proposed Rule Changes

On May 8^th, the Centers for Medicare and Medicaid Services (CMS) released the IRF PPS proposed rule changes for Fiscal Year 2014.  Among provisions in this year’s proposed rule that are of interest to infection prevention are:

• Reporting of CAUTI through NHSN (Pages 103 in proposed rule FR 26909, online p. 31):  This measure was first adopted for FY 2012 before it was endorsed by the National Quality Forum (NQF) for IRF settings, and updated last year once the measure was NQF-endorsed.  The reporting requirement for the IRF Quality Reporting Program (QRP) remains unchanged this year, but the measure has been renamed “National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) outcome measure (NQR #0138).