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Job Activities - The Gray Area, Non-Certified Staff Performing Sterile Processing Jobs

Updated: Apr 26

Sterilization/HLD responsibilities outside of SPD

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Thought of the Week

Numerous job activities related to reprocessing medical devices, including high-level disinfection (HLD) and sterilization, occur every day outside of the Sterile Processing Department (SPD). To date, only five states require certification for sterile processing technicians, those states are New Jersey, New York, Tennessee, Connecticut, and Pennsylvania. However, in some cases, staff inside and outside of the hospital environment might not be covered by the approved legislation. That doesn't mean that there aren't any requirements for staff reprocessing medical devices outside of Sterile Processing for those regions.


Where do states stand about non-certified staff performing sterile processing jobs?


New Jersey Subchapter 8. Central Service 8:43G-8.1


Central service policies and procedures

8:43G-8.2 Central service staff qualifications (a) There shall be a full-time director or supervisor of central service. (b) The director or supervisor of central services shall have two years of supervisory experience and shall be certified through a national sterile processing program recognized by the New Jersey Department of Health and Senior Services. (c) All personnel involved in sterile processing shall be certified through a national sterile processing program recognized by the New Jersey Department of Health and Senior Services within three years of employment and by August 2, 2009. (d) Personnel involved in the use of ethylene oxide shall have the appropriate licensure from the New Jersey Department of Environmental Protection.


New York CLS Pub Health § 2824

Nothing in this section shall prohibit any healthcare professional from performing central service technicians' tasks or functions if the person is acting within the scope of his or her practice. Nothing in this section shall mean that any individual not licensed pursuant to title eight of the education law may perform tasks or functions limited to the scope of practice of a healthcare professional under such title.

Connecticut Substitute House Bill No. 5913 Public Act No. 15-11

(e) Nothing in this section shall prohibit the following persons from performing the tasks or functions of a central service technician: (1) A Substitute House Bill No. 5913 Public Act No. 15-11 3 of 3 health care provider; (2) a student or intern performing the functions of a central service technician under the direct supervision of a health care provider as part of the student's or intern's training or internship; or (3) a person who does not work in a central service department in a health care facility, but who has been specially trained and determined competent, based on standards set by a health care facility's infection prevention or control committee, acting in consultation with a central service technician certified in accordance with subsection (b) of this section, to decontaminate or sterilize reusable medical equipment, instruments or devices, in a manner that meets applicable manufacturer's instructions and standards

Tennessee TN Code § 68-11-239


(4)

d) Nothing in this section shall prohibit the following persons from performing the tasks or functions of a central service technician:

(1) A healthcare provider operating within the scope of practice for that provider established pursuant to title 63;

(2) A surgical technologist operating within the scope of practice established by § 68-57-105;

(3) A student or intern performing the functions of a central service technician under the direct supervision of a healthcare provider as part of the student's or intern's training or internship; or

(4) A person who does not work in a central service department in a healthcare facility, but who has been specially trained and determined competent, based on standards set by a healthcare institution's infection prevention or control committee, acting in consultation with a central service technician certified in accordance with subsection (b), to decontaminate or sterilize reusable medical equipment, instruments, or devices, in a manner that meets applicable manufacturer's instructions and standards.

Pennslyvania Central Services and Surgical Technologist Regulation Act Section 102


Section 303. Scope of practice.

Nothing in this chapter may be construed to prohibit any of the following individuals from performing the tasks or functions of a central service technician:

(1) A health care practitioner.

(2) A dental assistant or an individual who is licensed or registered under the act of May 1, 1933 (P.L.216, No.76), known as The Dental Law.

(3) A student or intern performing the functions of a central service technician under the direct supervision of a health care practitioner as part of the student's or intern's training or internship.

(4) A person who holds or maintains a registration, certification or license by a nationally accredited credentialing organization to perform health services.

Section 304. Departmental duties.

The department shall administer the provisions of this chapter and promulgate and adopt such regulations as may be necessary to implement this act.


The Expansive Gray Area


For SPD technicians, Connecticut, Tennessee, New York, and Pennsylvania all require at minimum at least 10 CE hours annually, whereas New Jersey requires an education program within the Sterile Processing Department. As you can see by the documentation above there are immense caveats to the laws that were approved for the reprocessing of medical supplies. The key term is "Scope of Practice". Simply said, this allows for individuals outside of the SPD area to continue their practices without regard for certification or continuing education as required by law for SPD technicians, except N.J.


The Catch-All


Don't be left astray when it comes to non-certified staff performing sterile processing jobs. The wording of "Scope of Practice" allows individuals who work outside of the Sterile Processing Department to be accountable for their actions when it comes to the reprocessing of medical devices. First, as a part of the "scope," they must have job activities written within their job description that include the functions of reprocessing (e.g., decontamination, packaging, HLD, sterilization). Secondly, they must follow the instructions for the use of the items they are reprocessing. Lastly, they must also have competencies for their job activities written within their job description.


The Key Takeaway


Just about anyone who has participated in an RCA event regarding the reprocessing of a medical device outside of the sterile processing environment has been told that the Sterile Processing Department is the expert. Typically, during those events, the SPD department is asked to take on the reprocessing from the department that failed in practice. That is not always possible. Consultation with the Sterile Processing Department and Infection Control should be routine for any department reprocessing medical devices.





At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.



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