1. Wyoming Infection Prevention 4th Annual Infection Prevention Conference Casper, WY Russ Forney, PhD, MT(ASCP) Healthcare Survey & Licensing Aging Division, WY Dept of Health

2. Good morning, we are here to survey your facility... Your Survey just started...

3. Survey Summary (2012-2013)

4. WYOMING (N=19)REGION 8 (N=271)NATION (N=2164) TypeDescription% SurveysTagDescription% SurveysTagDescription% Surveys LTC ASC ACH CAH Infection Control Program 56% ACH LTC ASC CAH Infection Control Program 40% ACH ASC LTC Medications38% ASC ACH CAH Infection Control (Safe, Sanitary Environment, Surgical Services) 33% LTC ASC ACH CAH Medications35% ASC LTC ACH CAH Infection Control Program 33% LTC ASC ACH Patient Rights Resident Rights 32% ASC LTC ACH CAH Infection Control (Safe, Sanitary Environment, Surgical Services) 35% ASC LTCF ACH CAH Infection Control (Safe, Sanitary Environment, Surgical Services) 28% LTC ASC ACH CAH Medications32% ASC LTC ACH CAH Infection Control (Condition) 22% LTC ASC ACH Patient Rights Resident Rights 20% LTC ASC ACH CAH Infection Control (Condition) 12% ASC LTC Admission & Assessment 18% ASC LTC ACH Advanced Directives, Consents 17%

5. Sources of evidence –Observation –Interview –Document review Evaluation of findings Determine if non-compliance exist Intra-office QA process Survey Process

7. Infection control: A747 (ACH), C278 (CAH), Q240 (ASC) Surgical services A940 (ACH), C320 (CAH), Q060 (ASC) F441: Infection control (LTC) Q181: Medication administration (ASC) Frequent Findings (2012-2013)

8. Acute Care and Long-Term Care

9. Surveillance activities Sterile processing High-level & environmental disinfection Terminal OR cleaning Sterile (controlled) storage & tracking It is more difficult (complex processes) to reprocess an endoscope than it is to use it Infection Control: Acute Care “Outside” specialties

10. Surveillance activities: outcome & process Data collection: active & passive Environmental tour Hand hygiene Monitor all areas within the facility Long-term care is a challenging infection control setting - it is hard work! Infection Control: LTC

11. Infection control is a never-ending story, ongoing training for surveyors Increasing complexity in the survey process for all facilities, notably ACH (PSI program) Adding surveyors to the LTC team: formal training and OJT on site (survey) HLS: The Next Generation

12. Online IC database Network Annual IC conference IP manual (2014) Other facilities, QIO, associations, WDH, regional affiliations (VA, ESRD, QIO) Valuable Resources

13. Questions?

14. Russ Forney, PhD, Healthcare/CLIA surveyor russ.forney@wyo.gov 307-777-7123 Healthcare Licensing & Surveys Aging Division Wyoming Department of Health Contact Information