Assess Your EVS Program for Infection Control Problems Before Surveyors Show Up

By A.J. Plunkett

Assess your environmental cleaning protocols, ensure staff are trained properly, and verify the effectiveness of both as CMS increases scrutiny of infection prevention and control during the coronavirus pandemic.

Earlier this year CMS cited hospitals for not following their own policies and failing to ensure environmental services (EVS) personnel followed standard procedures for infection control during cleaning, including instances of cross-contamination of surfaces.

In one example, a hospital was cited under Condition of Participation (CoP) §482.42: Infection Prevention and Control and Antibiotic Stewardship Programs, which according to CMS’ State Operations Manual (SOM), Appendix A, states:

“The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs [healthcare-acquired infections] and other infectious diseases, and for the optimization of antibiotic use through stewardship.

“The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms.

“Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program.”

The hospital was cited under the SOM A-Tag A-0747 after, among other things, surveyors watched an EVS aide clean an operating suite between procedures by removing the suction canisters and basin containing bloody secretions and placing them on a surgical table.

“Then without changing his contaminated gloves, he retrieved bottles of solidifier, multiple times from his pockets. The same staff member was later observed failing to clean all surfaces of a Bear Hugger, surgical table, and a standing circular tray, then cross contaminating a surgical table by placing a dirty pillow on the previously cleaned table surface,” according to the CMS deficiency report.

In another example, a hospital was cited under tag A-0747 for the same CoP, which says hospitals should have an infection prevention and control program with documented policies and procedures that employ “methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.”

That hospital was cited after CMS surveyors observed an EVS worker cleaning a patient room, using a wet towel to wipe a garbage can, “then proceeded to wipe the sink, walls and window sill with the same towel, until intercepted by the facility’s staff.”

Training and educating staff, and verifying the training and the effectiveness of the cleaning are keys to a good EVS program, says Robert Albrecht, a former environment of care director at a hospital in Washington, D.C., who now offers cleaning services and consulting through his own firm as president of Infection Prevention Systems in Havre de Grace, Maryland.

Assessment and evaluation

Begin the evaluation of your environmental services program with an assessment of cleaning protocols, which should include a full evaluation of products, equipment, and supplies, combined with the frequency and thoroughness of your processes, says Albrecht.

You should already have an inventory of products, supplies, and equipment you use as part of your program. Make sure that inventory is updated with new products, new chemicals and their safety data sheets (SDS), and any new procedures, especially anything that requires new steps or products because of the coronavirus pandemic, notes Albrecht.

Standard operating procedures (SOP) should include any area-specific systematic cleaning. This includes how frequently the cleaning is done, how quality assurance is performed, and how personnel training is recorded, he says.

Remember that CMS and other surveyors will be comparing procedures and SDSs with manufacturers’ information for use of any products.

Some cleaning supplies are meant to be used as part of a system with specific equipment, such as a microfiber wipe or a disposable paper towel, notes Albrecht.

“The frequency of use is usually dependent on the healthcare provider’s assessment,” he says. As you are evaluating your SOP, make sure cleaning systems and frequency of use are aligned, he urges.

“The assessment is solely to identify what products are used in conjunction with the SOP and if there is synergy to effectively clean while disinfecting specific areas,” says Albrecht. “The proper use of products is either determined through direct observation, elimination of visible debris, or by analytical methods. Once an assessment has been conducted, then recommendations can be made to enhance, rewrite, or accept the existing protocols by EVS directors.”


Hospitals generally train EVS staff how to use products based on manufacturers’ recommendations and the procedures needed for various areas, whether it’s turning over a room or cleaning public areas, notes Albrecht.

But the theory of cleaning vs. sanitizing vs. disinfection is generally not included as part of the overall program. And it needs to be, says Albrecht. “Just like any trade, staff must know the fundamentals before they can implement an effective cleaning protocol,” he notes.

EVS personnel should understand the following:

  • Cleaning is the removal of organic and inorganic debris and is the first step in disinfection or sanitization.
  • Sanitizing is treatment of a cleaned surface to effectively destroy microorganisms to a certain degree for public safety purposes. “This term is used frequently in the food production and food service industry,” says Albrecht.
  • Disinfection is the destruction of microbial contamination to a level that is higher than sanitizing but lower than sterilization.

Staff should be educated on products, policies, and procedures at date of hire, during their first weeks on-site, and whenever there are changes to the system or to equipment, chemical agents, or other cleaning materials.

Then EVS staff should be evaluated on their knowledge levels. “Ask them questions in a manner that affords trust and if possible, privately,” encourages Albrecht.

Remember to retrain and reinforce education if you make changes improvements during the assessment phase, he advises.

How effective is your system?

Finally, you must verify the effectiveness of your cleaning protocols.

“Many facilities are using ATP [adenosine triphosphate] or markers that are illuminated with blacklight, but there are many other systems that can be used to verify the level of cleaning,” says Albrecht.

The important thing is to verify that what you think you are cleaning is actually getting clean.

“ATP is one tool in the toolbox that provides instant results with a high level of accuracy, but it is not the only means we use,” says Albrecht. “The most effective way to assess the level of cleanliness is to use several modes.”

Some modes of assessment are quantitative, he says, such as using ATP, settling dishes, air/swipe samples, or particle counters. Others such as UV markers, white glove testing, or tweezer extraction are qualitative.

Whatever mode the hospital uses, it should use that mode “in a consistent manner,” he says. “Collection of that data should also be recorded and used over time to establish baseline levels for the specific facility and compare to like-kind data points either from research or other facilities.”

There are many resources available free and for purchase to help EVS managers. “We use a proprietary method that includes a risk assessment prior to any other work to identify high-risk areas, personnel, and frequent modes of transmission,” says Albrecht.

The CDC also has a number of tools on its website, including a program for evaluating environmental cleaning.

CMS and other accreditation organizations want to see improvement. And remember it is expected under the infection prevention CoP.

Whatever the method, “we recommend that each facility purchase or create aids that will foster improvement in the level of cleanliness,” Albrecht says.