Certain Infection Control Breaches to be Referred to Public Health Authorities

The Centers for Medicare and Medicaid Services (CMS) has issued S&C letter 14-36, directing surveyors to report to the appropriate state authority serious infection control breaches. CMS points out that some types of infection control breaches, including some specific to medication administration practices, pose a risk of blood borne pathogen transmission that warrant engagement of public health authorities to conduct risk assessment and, if necessary, to implement the process of patient notification. These functions are outside the jurisdiction of CMS, but do fall within the authority of State public health agencies. The types of breaches that should be reported by survey staff include:

• Using the same needle for more than one individual;
• Using the same (pre-filled/manufactured/insulin or any other) syringe, pen or injection device for more than one individual;
• Re-using a needle or syringe which has already been used to administer medication to an individual to subsequently enter 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.

Contact: Elliott Frost, efrost@leadingageny.org, 518-867-8832