CMS SOM App. E, Tag I-160

The organization that provides outpatient physical therapy services establishes an

infection-control committee of representative professional staff with responsibility

for overall infection control. All necessary housekeeping and maintenance services

are provided to maintain a sanitary and comfortable environment and to help

prevent the development and transmission of infection.

Interpretive Guidelines §485.725

A - General

This condition applies to all organizations as providers of physical therapy and/or speech-language pathology services. Any services provided by a rehabilitation agency are subject

to the agency’s Infection Control policies and procedures.

An infection control committee, applicable for organizations offering physical therapy or

speech-language pathology services, has overall responsibility for ensuring that

environmental infection hazards are controlled. The committee should consist of staff

representing the various professional services provided by the organization and should

ensure that the organization has up-to-date infection control policies and procedures for

investigating, controlling, and preventing infections in the organization; as well as

monitors staff performance to ensure that the policies and procedures are being executed.

Review the organization’s Infection control policies and procedures. The organization

must have the necessary housekeeping staff and supplies to maintain a sanitary

environment.

The organization must investigate infections acquired by patients that occur after

treatment using equipment such as a whirlpool or instruments used in debriding a wound.

If the organization is providing services at more than one location per day, there should

be infection control policies in place for all locations. These policies should set forth the

techniques agency employees must use to prevent cross-contamination of patients

between locations. For example, when an organization is providing services to patients in

a skilled nursing facility and then they travel next door to provide treatment to patients in

an assisted living facility, the staff will wash their hands before treating patients.

B - Major Sources of Information

• Written policies and procedures;

• Minutes of the infection control committee meetings;

• Interviews with staff, patients, and administrator; and

• Observations.