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Note #2: A spore test for July 2015did not indicate that acontrol was ran with <br />the test. Corrective Action: Further education and training with staff to be <br />completed by January 31" 2016. See attached document. <br />Note #: The autoclave broke down |nJuly JO15 was available <br />showing that the autoclave was repaired. |tisrecommended that the <br />documentation showingthetime and temperature ofthe loads indicate that the <br />loads failed, were ran again. Corrective Action: Further education and training <br />with staff twbe completed bvJanuary 31st%D1G' <br />|nfurther response tnyour notes: VVehave also partnered with Stericycle to do <br />extensive monthly inspections, including taking photos. These Integrated Waste Stream <br />Solutions HSS Rounding Reports will be shared in monthly meetings with our <br />Environment of Care Committee and front line nursing supervisors; these reports and <br />meetings will help tmfacilitate further educating our staff and prompt and necessary <br />furthertrainiugs' See attached document titled 'Stedcyde_HSGRounding' <br />JomKendle <br />Senior Service Area Director, Support Services <br />