Download Chapter 7:I

Subchapter 7.I – Infection Prevention & Control
Possible Survey Review Items
This list represents some of the items that an AAAHC surveyor may review during an on-site
survey.
Subchapter 7.I – Infection Prevention & Control
 Program
 Approved by the board
 Integral part of QI
 Designated and qualified director
 Meets applicable state and federal requirements
 Plan of Action
 Preventing, identifying, and managing infections
 Implementing corrective and preventive measures → improvement
 Process for monitoring and documenting high level disinfection & sterilization
 Critical – enters sterile tissue or vascular system
 Semi critical – touches mucous membranes
 Non critical – touches intact skin
 Manufacturer recommendations are followed for the cleaning and disinfection of medical
devices
 Sharps injury prevention program
 Documentation of orientation and annual training
 Disposal into appropriate sharps containers
 Placement of sharps containers in appropriate care areas
 Replacement of filled sharps containers
 Disposal of filled sharps containers
 Policy defining the process if sterilization parameters fail
 Policy concerning the isolation and transfer of patient’s with communicable diseases
 Written policy addressing the cleaning and care of patient treatment care areas
 Cleaning before use
 Cleaning between patients
 Terminal cleaning at the end of the day
 Manufacturer recommendations are followed for cleaning and an EPA-registered
disinfectant is used
 Training of staff – at initial employee orientation and annually
 Hand hygiene (adopting nationally-recognized guidelines for safe injections)
 PPE
 Injectable medications, saline and other infusables (adopting nationally-recognized
guidelines for safe injections)
 Needles and syringes used for only one patient
 Single dose medication vials
 Multi- dose vial protocol
Updated 1.1.2015