Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
07.04.03 Processing flexible and semi-rigid endoscopes Frequency of the citation: 26%
The goal of the standard is to ensure that reusable endoscopes are decontaminated, cleaned, and stored according to recognized standards to mitigate the risk of contamination and damage. ■ Audit policy for inclusion of all required elements. ■ Audit inventory for relevant classification. ■ Audit storage for compliance with time-sensitive reprocessing expectations. ■ Engage a collaborative team with representatives of surgical services, endoscopy, sterile processing, respiratory services, facilities, QAPI, and infection prevention to review and make recommendations regarding policy and procedures.
Nerd Newbies (understand the requirement)
Overview of the requirement: The hospital adopts nationally recognized guidelines for classifying endoscope inventory as critical, semi- critical, or non-critical and establishes cleaning, disinfection, and sterilization processes in accordance with classification guidelines. Comment on deficiencies: Compliance is assessed through observation, interview, and review of policy and process documentation. Surveyor citations focused on policies that lacked required elements and processing practices that diverged from policy requirements. Examples of ACHC Surveyor findings: ■ Scopes located outside the endoscope drying cabinets were tagged as reprocessed within seven days in accordance with hospital policy. The scope cleaning log lacked evidence of the processing as recorded on the tags. ■ The latest processing date for bronchoscopes, ready to be used, was noted to be more than 14 days prior to survey. This is not consistent with hospital policy which states "Remove and reprocess the endoscope before use if seven-day storage time has been exceeded." ■ Elements were missing from the policy: ٝ Point of use treatment: Does not discuss time frame within which scope cleaning has to start. ٝ Transporting: No mention of the number of scopes that can be transported in bin at one time. ٝ Leak testing: No mention of space requirement. ٝ Decontamination/cleaning: No delayed cleaning procedure. ٝ Safe storage: Policy states scopes should be hung horizontally instead of vertically. ٝ Personnel education, training, and competency verification. ٝ Classification of the endoscope inventory. ٝ Unidirectional workflow for device processing: Section needs expansion and clarification. ٝ Required lighting and magnification for scope inspection. ٝ Water quality plan. ■ The scope processing area lacks a dual sink, and the hospital lacked evidence of a consistent process for using freshly cleaned containers for leak testing, manual cleaning, and rinsing, compromising the cleaning of the scopes.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
CHAPTER 08: MATERIALS MANAGEMENT 08.00.03 Safe storage of supplies Frequency of the citation: 45%
Overview of the requirement: Storage of items that support patient care is appropriate to their use and protects from damage or loss. Comment on deficiencies: Compliance is assessed through observation. Deficiencies noted commingled storage of medications and supplies, shelving that did not meet requirements, and inadequate efforts to limit access to supplies.
Examples of ACHC Surveyor findings: ■ Clean supplies were stored in the dirty utility room in a patient care area.
■ Materials management: Containers of clean supplies were observed on the floor of a storage room. ■ The hospital's risk assessment for storage lacked evidence of reasonable attempts to segregate supplies, review by the infection preventionist, and review and approval by the Infection Control Committee. ■ Laboratory storage did not meet requirements for a minimum distance of six inches above the floor for lowest shelving height and a solid protective barrier. ■ Multiple departments stored cleaning supplies and patient supplies together. ■ The phlebotomy room door was propped open and left unattended allowing access to needles, syringes, and other venipuncture supplies.
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