Need a Documented Infection Control Program and Plan with
Your Name here
Date
Recommendations: Need to hire a Certified Infection Preventionistto develop, implement, manage, monitor, and maintain the Infection Prevention program. Attempt to come into compliance with as much as you can by ___. Ask DPH for more time to comply while showing an effort to become compliant with the time constraints.
I. Infection Control Program and Plan /
Need a documented Infection Control Program and Plan with :
- Infection Control Policies and Procedures to include CDC definitions and criteria.
- Annual Risk assessment and documentation
- Plan to include surveillance with measurable indictors for surgical site infection (SSI) monitoring, as well as monitoring process measures.Report to the Infection Control or Quality Committee on a quarterly basis.
- Sterilization and reprocessing policy and procedure and documentation via logs
- Documented education and competencies for all infection prevention strategies plans, sterilization, reprocessing procedures for all staff and Licensed independent practitioners (LIP)
- Appropriate disposal of Pharmaceutical waste in the OR suite with documented policy and procedure to include education to staff and LIP’s
- Appropriate environmental cleaning policy and procedures
- Appropriate policy and procedures for the management of patient equipment and the routine cleaning of thatequipment.
- Policy and procedure to manage safe medication practices
Environment Of Care /
- Proper cleaning of the environment with EPA approved healthcare grade disinfectants
- Schedule of this routine cleaning in the sterile and non sterile areas to include the OR and procedural rooms
- Terminal cleaning of OR’s to be done at the end of everyday.
- Routine inspection of equipment to include mattress in OR.
- Proper cleaning, reprocessing and high level disinfection of endoscopes with policy and procedures documented and staff competency documented
- Appropriate monitoring and maintaining of OR temperature and humidity
- Proper sterilization management
- Maintaining sterile fields and technique within the OR
Infection Control Education /
- Documented annual and as needed Infection Prevention training for all staff and LIP’s
ATD Management Plan /
- Documentation that all direct patient care providers to include LIP’s have annual TB screening and annual training.
- Policy and procedure needed.
Communicable Disease Reporting to Public Health (PH) /
- Process to report communicable diseases to PH per Title 17 requirements.
- Documentation of all staff and LIP’s vaccination status for required vaccines for health care workers.
Policy and Procedure /
- Review of all Policy and Procedures to comply with CA state mandates, regulatory requirements and CDC recommendations and definitions
Blood Borne Pathogen Exposure Control Plan /
- Documentation of a BBP exposure control Plan and documented education annually to staff and LIP’s
- Documentation of sharp safety devices selected and used
Regulatory, state, federal compliance /
- Compliance with state and local mandates, CMS, The Joint Commission and any other regulatory body like USP 797.
Hand Hygiene program /
- Develop Policy and procedures and document education and compliance reported out to Quality or IC committee
Respiratory Etiquette Program /
- Develop Policy and procedures and document education and compliance reported out to Quality or IC committee
Safe injection practices /
- Develop Policy and procedures and document education and compliance reported out to Quality or IC committee