Expectations of Hospitals Relative to Infection Control: 42 CFR 482.42
Dodgie Guioa, CMS trainer and experienced nurse in Psychiatry, Oncology, Surgery, presented a very engaging program addressing the issues that regulatory agencies expect Infection Preventionists to oversee. He emphasized that the hospital must strive for high reliability and safety using an active program for prevention, control and investigation of infections. Regulatory agencies use observation, interviews and record reviews to conduct their evaluations of agencies, and the Infection Preventionist should also have an ongoing method of applying these three techniques. The purpose of the Infection Preventionist is to be on looking for breaches in compliance with standards for infection control throughout the entire facility. The Infection Preventionist should use a risk assessment process for determining elements of action plans and should share action plans with the hospital Quality Management Department and Executive Office leadership. Antibiotic stewardship, an essential element of infection prevention, must be outlined in an evidence based policy and overseen by pharmacy service. An ongoing system should be in place to evaluate the staff compliance with infection control competencies including hand hygiene, injection safety, environmental hygiene, dietary sanitation, medical equipment disinfection, and maintenance of surgical asepsis.