Home Health & Hospice

CMS to surveyors: Certain infection control breaches warrant referral to authorities

Homecare Insider, June 16, 2014

CMS recently issued a memorandum to state survey agency (SA) directors outlining specific infection control breaches that, when identified by either state surveyors or accrediting organization (AO) surveyors, should be referred to state authorities for public health assessment and management. The instructions outlined in the memorandum are effective immediately. Certain infection control breaches pose a risk of bloodborne pathogen transmission and should be referred to public health authorities so that they can conduct appropriate risk assessment and—when necessary—notify patients about potential threats.

The memo directs SAs to consult with their state’s healthcare associated infections prevention coordinator or epidemiologist to identify the preferred referral process for such breaches, while AOs are expected to refer the breaches to the appropriate state public health contact.
Breaches that warrant disclosure to public health authorities include:
  • Using the same needle for more than one individual
  • Using the same syringe, pen, or injection device for more than one individual
  • Inserting a needle or syringe that has already been used to administer medication to an individual into a medication container (e.g., vial, bag), and then using contents from that medication container for another individual
  • Using the same lancing/fingerstick device for more than one individual, even if the lancet is changed
SAs may refer other infection control breaches if recommended by their state public health authorities. AOs also have the discretion to refer additional breaches they believe require public health assessment and management.