Posted in: Triangle Times Today

Volume 2 | Issue 2 | February 2023

v42 Standards Q&A Series

During the Q&A session that followed the two live v42 Standards webinars presentations, attendees had a variety of questions regarding updates, impact, and readiness. AAAHC staff and faculty captured those exchanges and will feature excerpts of them in future issues of this newsletter.

The first of this series features the topic of infection prevention and control (IPC). As we are currently seeing resurgences of COVID-19, flu, and other
seasonal illnesses, AAAHC presents this information as the first topic in our continuing series.

What is the
requirement for
studies? Can they
be repeated?

Benchmarking study is defined as a systematic comparison of similar products, services, or work processes to identify the best practices known to date for the purpose of continuous quality improvement. When the results of benchmarking indicate that performance improvement is needed, appropriate quality improvement activities should be undertaken to ensure that improvement occurs.

If the benchmarking results indicate that little to no further improvement is needed, the organization should seek to undertake a new study that is aimed at performance improvement.

What resources
are available for
hand hygiene

The CDC, APIC, and AORN provide examples of tools for hand hygiene monitoring specific to the out patient and ambulatory setting.

What is the
requirement for
terminal cleaning?

AAAHC Standards require that the organization has written policies to address terminal cleaning frequency based on the use of the area and best practice guidelines.

require an IPC risk
assessment for
each location?

AAAHC Standards require a tuberculosis detection and protection plan that follows existing health authority and/OSHA/or nationally recognized guidelines.

Do emails meet
requirements for
staff training and

Organizations should deliver and document training in accordance with policies and procedures, based on best practices.

What are AAAHC requirements on
remote employees receiving IPC,
vaccination, and safety training?

AAAHC Standards are not explicit about remote versus onsite employees’ vaccination and training requirements. Refer to OSHA requirements.

Does AAAHC require training for all staff
on equipment sterilization?

AAAHC Standards require that staff who sterilize equipment receive appropriate training.

Where can you store a multidose vial?

AAAHC Standards require a program for infection prevention and control which includes safe injection practices and that medications are stored and managed in accordance with manufacturer, state, and CDC guidelines. Additional resources include:

• AAAHC Safe injection Practices Toolkit
• CDC One & Only Campaign

What are the requirements for
medication disposal containers?

The EPA released a 10-step Blueprint for Managing Pharmaceutical Waste in US Healthcare Facilities (Oct 2022).

Which AAAHC requirement can
confirm length of time to use drawn up

AAAHC Standards require that the organization follows the manufacturer and/or FDA instructions for medication/product specific instructions for length of time to use drawn up medications.

What medical settings does the CDC One
& Only Campaign apply to?

According to the CDC, the One & Only Campaign applies to any health care facility that administers medications with a syringe.

Which safety requirement addresses
locations of eye wash stations?

AAAHC Standards require organizations have a policy defining the minimum equipment and supplies required for emergencies and those equipment and supplies should be readily accessible. Refer to OSHA on requirements for eyewash stations.

What documentation is required for failed
equipment (i.e., sterilization cycles)?

AAAHC Standards require a written policy that addresses the identification and processing of medical equipment and instruments that fail to meet high-level disinfection or sterilization parameters. Additionally written policies and documentation of preventive maintenance according to manufacturer’s instructions is present.

Is it a requirement to have locking lids
on sharps containers?

AAAHC Standards require a sharps injury prevention program that includes the placement of sharps containers in areas secured from tampering.

What kind of flooring should be placed in
public and patient care areas?

Flooring placed in public and patient areas must be able to be cleaned effectively and withstand the cleaning products used.

Does AAAHC require the brand name of
supplies (i.e., Sani-Cloth® ) in policies?

AAAHC Standards are not prescriptive regarding brand names of supplies.

Missed the v42 webinar? View the complimentary, recorded presentation at

Conferences & Exhibits

  • Texas Ambulatory Surgery Center Society (TASCS)
    Mar 7–8

1095 Learn

  • Mar Achieving Accreditation Virtual
    Mar 20–22

This March, AAAHC will return to its virtual conference platform

Attendees will experience all the information and activities of a live conference from the comfort of your office, den, or kitchen table. Covering topics, such as v42 handbooks and quality improvement, attendees will come away with new understanding, fresh perspectives, and the feeling of time well spent. To learn more, visit our website.

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