Most Common Deficiencies For Chapter 7-I “Infection Prevention and Control”
The most common deficiencies our surveyors see for Chapter 7-I “Infection Prevention and Control” of the AAAHC Accreditation Handbook for Ambulatory Health Care:
There must be a formal documented infection prevention risk assessment. This is often missing.
The person approved as responsible of infection control must have obtained training in infection prevention and control. This training should be more than what other staff members receive in training. And, there should be evidence of this training.
Internal and external indicators including biological indications are used for all items undergoing sterilization. Employees who conduct sterilizations should be able to explain and show evidence of this.
The manufacturer’s instructions for use of equipment should be present in the sterilization room.
Sterilization personnel must be able to answer what they would do if the sterilization failed.
The most common missing standard for Infection Control Programs is the lack of a written policy for isolation or immediate transfer of patients with communicable diseases. Having a statement that the center does not admit patients who are contagious is not acceptable. The intent of this requirements focuses on patients identified as contagious after being admitted, such as in pre-op.
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience