Infection Control Worksheet Form PDF Details

In the realm of healthcare, maintaining stringent infection control practices is paramount, especially within ambulatory surgical centers (ASCs) where the risk of infection can significantly impact patient safety and outcomes. To this effect, the Infection Control Surveyor Worksheet serves as a crucial tool designed to assess compliance with established infection control Condition for Coverage. This comprehensive worksheet mandates thorough on-site evaluations by surveyors, encompassing a broad spectrum of items which are examined primarily through direct observation and complemented by interviews. These interviews ideally involve staff members most knowledgeable about specific infection control practices, ranging from sterilization protocols to the handling of surgical instruments. Even the observation of a minimum of one surgical procedure forms a part of this evaluation, ensuring a wide-ranging assessment that covers the characteristics of the ASC, such as the types of procedures performed, the patient demographics served, and the facility's ownership and operational details. Moreover, the worksheet delves into the ASC's infection control program, scrutinizing its adherence to nationally recognized infection control guidelines, the qualification and training of personnel dedicated to infection control, and the mechanisms in place for identifying and tracking infection-related incidents post-procedure. Additionally, the worksheet evaluates the infection control training provided to staff members, emphasizing the importance of ongoing education in maintaining high standards of infection prevention and control. This meticulous approach embodied in the Infection Control Surveyor Worksheet underscores a commitment to safeguarding public health by ensuring ASCs operate within the highest standards of infection control.

QuestionAnswer
Form NameInfection Control Worksheet Form
Form Length15 pages
Fillable?Yes
Fillable fields83
Avg. time to fill out20 min 21 sec
Other namessurveyor worksheet, infection control worksheet printable, cms cop infection control worksheet, control surveyor worksheet

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Attachment

Exhibit 351

 

INFECTION CONTROL SURVEYOR WORKSHEET

Name of State Agency or AO (please print at right) _________________________________________________

Instructions: The following is a list of items that must be assessed during the onsite survey, in order to determine compliance with the infection control Condition for Coverage. Items are to be assessed primarily by surveyor observation, with interviews used to provide additional confirming evidence of observations. In some cases information gained from interviews may provide sufficient evidence to support a deficiency citation.

The interviews and observations should be performed with the most appropriate staff person(s) for the items of interest (e.g., the staff person responsible for sterilization should answer the sterilization questions).

A minimum of one surgical procedure must be observed during the site visit, unless the ASC is a low volume ASC with no procedures scheduled during the site visit. The surveyor(s) must identify at least one patient and follow that case from registration to discharge to observe pertinent practices. For facilities that perform brief procedures, e.g., colonoscopies, it is preferable to follow at least two cases.

When performing interviews and observations, any single instance of a breach in infection control would constitute a breach for that practice.

Citation instructions are provided throughout this instrument, indicating the applicable regulatory provision to be cited on the Form CMS‐2567 when deficient practices are observed.

PART 1 – ASC CHARACTERISTICS

 

 

 

 

 

 

 

 

 

 

 

1. ASC Name (please print)

 

 

 

 

 

 

 

 

 

 

 

2. Address, State and Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

(please print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. 10digit CMS Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.What year did the ASC open for operation?

5. Please list date(s)

 

 

 

/

 

 

of site visit:

m m

 

d d

y y y y

/

y y y y

to m m

/

/

d d y y y y

6.What was the date of the most recent previous federal (CMS) survey:

/

m m

/

d d y y y y

PLEASE COMPLETELY FILL IN EACH BUBBLE USING A DARK PEN.

7. Does the ASC participate in Medicare via accredited “deemed” status?

YES

NO

 

7a. If YES, by which CMSrecognized accreditation organization?

(Check only ONE):

Accreditation Association for Ambulatory Health Care (AAAHC)

American Associate for Accred. of Ambulatory Surgery Facilities (AAAASF)

American Osteopathic Association (AOA)

The Joint Commission (TJC)

7b. If YES, according to the ASC, what was the date of the most recent accreditation survey?

/

m m

/

d d y y y y

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8. What is the ownership of the

Physicianowned

facility?

Hospitalowned

 

 

National corporation (including joint ventures with physicians)

 

 

 

 

Other (please print):

 

 

 

 

 

9. What is the primary procedure performed at the

10. What additional procedures are performed at the

ASC (i.e., what procedure type reflects the majority of

ASC? (Fill in all that apply)

procedures performed at the ASC)?

Do not include the procedure type indicated in

(Fill in only ONE bubble)

question 9.

Dental

Endoscopy

Ear/Nose/Throat

OB/Gyn

Ophthalmologic

Orthopedic

Pain

Plastic/reconstructive

Podiatry

Other (please print):

Dental

Endoscopy

Ear/Nose/Throat

OB/Gyn

Ophthalmologic

Orthopedic

Pain

Plastic/reconstructive

Podiatry

Other (please print):

 

11. Who does the ASC perform

Pediatric patients only

 

 

 

 

 

 

 

 

 

 

 

 

procedures on?

Adult patients only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Fill in only ONE bubble)

Both pediatric and adult patients

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. What is the average number of

 

 

 

 

 

 

 

 

 

 

 

per month

 

 

procedures performed at the ASC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

per month?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. How many Operating Rooms (including procedure

 

rooms) does the ASC have?

 

1

 

2

3

 

 

4

 

5

6

7

8

9+

 

Number actively maintained:

 

 

 

1

 

2

3

 

 

4

 

5

6

7

8

9+

 

 

 

 

 

 

 

 

14. Please indicate how the following services are provided: (fill in all that apply)

 

 

 

 

 

 

 

 

 

Contract

Employee

Other

 

 

 

 

 

If Other, Please print:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anesthesia

 

 

 

 

 

 

 

 

 

 

 

 

Environmental Cleaning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Linen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sterilization/Reprocessing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Waste Management

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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INFECTION CONTROL PROGRAM

15. Does the ASC have an explicit infection control program?

YES

NO

 

NOTE! If the ASC does not have an explicit infection control program, a conditionlevel deficiency related to 42 CFR 416.51 must be cited.

16. Does the ASC’s infection control program follow nationally recognized infection

YES

control guidelines?

NO

NOTE! If the ASC does not follow nationally recognized infection control guidelines, a deficiency related to 42 CFR 416.51(b) must be cited. Depending on the scope of the lack of compliance with national guidelines, a conditionlevel citation may also be appropriate.

16a. Is there documentation that the ASC considered and selected nationally

YES

recognized infection control guidelines for its program?

NO

 

 

 

 

 

16b. Which nationally

CDC/HICPAC Guidelines:

 

recognized infection

Guideline for Isolation Precautions (CDC/HICPAC)

control guidelines has

Hand hygiene (CDC/HICPAC)

 

the ASC selected for its

 

 

 

program?

Disinfection and Sterilization in Healthcare Facilities (CDC/HICPAC)

(Fill in all that apply)

 

 

Environmental Infection Control in Healthcare Facilities (CDC/HICPAC) Perioperative Standards and Recommended Practices (AORN)

Guidelines issued by a specialty surgical society / organization (List)

Please specify (please print and limit to the space provided):

Others

Please specify (please print and limit to the space provided):

NOTE! If the ASC cannot document that it considered and selected specific guidelines for use in its infection control program, a deficiency related to 42 CFR 416.51(b) must be cited. This is the case even if the ASC’s infection control practices comply with generally accepted standards of practice/national guidelines. If the ASC neither selected any nationally recognized guidelines nor complies with generally accepted infection control standards of practice, then the ASC should be cited for a conditionlevel deficiency related to 42 CFR 416.51.

3 of 15

17. Does the ASC have a licensed health care professional qualified through training YES

in infection control and designated to direct the ASC’s infection control program?

NO

 

NOTE! If the ASC cannot document that it has designated a qualified professional with training (not necessarily certification) in infection control to direct its infection control program, a deficiency related to 42 CFR 416.51(b)(1) must be cited. Lack of a designated professional responsible for infection control should be considered for citation of a conditionlevel deficiency related to 42 CFR 416.51.

 

17a. If YES, Is this person an:

 

 

 

ASC employee

 

(Fill in only ONE bubble)

 

 

 

ASC contractor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

17b. Is this person certified in infection control (i.e., CIC) (

Note: §416.50(b)(1)

 

does not require that the individual be certified in infection control.

)

NO

 

 

 

 

 

 

 

 

 

 

 

17c. If this person is NOT certified in

 

 

 

 

 

 

 

 

 

 

infection control, what type of infection

 

 

 

 

 

 

 

 

 

 

control training has this person received?

 

 

 

 

 

 

 

 

 

 

 

17d. On average, how many hours per week

 

 

 

hours per week

 

 

 

 

does this person spend in the ASC directing

 

 

 

the infection control program?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Note: §416.51(b)(1) does not specify the amount of time the person must spend in the ASC directing the

 

 

infection control program, but it is expected that the designated individual spends sufficient time onsite

 

 

 

directing the program, taking into consideration the size of the ASC and the volume of its surgical activity.

)

18. Does the ASC have a system to actively identify infections that may have been

YES

related to procedures performed at the ASC?

 

 

 

NO

18a. If YES, how does the ASC

The ASC sends emails to patients after discharge

obtain this information?

The ASC followsup with their patients’ primary care providers after

(Fill in ALL that apply)

 

discharge

 

 

 

The ASC relies on the physician performing the procedure to obtain

 

 

this information at a followup visit after discharge, and report it to

 

 

the ASC

 

 

 

 

Other (please print):

 

 

 

 

 

18b. Is there supporting documentation confirming this tracking activity?

YES

NO

 

NOTE! If the ASC does not have an identification system, a deficiency related to 42 CFR 416.44(a)(3) and 42 CFR 416.51(b)(3) must be cited.

18c. Does the ASC have a policy/procedure in place to comply with State

YES

notifiable disease reporting requirements?

NO

NOTE! If the ASC does not have a reporting system, a deficiency must be cited related to 42 CFR 416.44(a)(3). CMS does not specify the means for reporting; generally this would be done by the State health agency.

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19. Do staff members receive infection control training?

YES

NO

 

19a. If YES, how do they receive infection control training?

(Fill in all that apply)

Inservice

Computerbased training

Other (please print):

19b. Which staff members receive infection control training?

(Fill in all that apply)

Medical staff

Nursing staff

Other staff providing direct patient care

Staff responsible for onsite sterilization/highlevel disinfection

Cleaning staff

Other (please print):

19c. Is training:

the same for all categories of staff

 

 

different for different categories of staff

19d. Indicate frequency of staff infection control training

(Fill in all that apply)

Upon hire

Annually

Periodically / as needed

Other (please print):

19e. Is there documentation confirming that training is provided to all

YES

categories of staff listed above?

NO

NOTE! If training is not provided to appropriate staff upon hire/granting of privileges, with some refresher training thereafter, a deficiency must by cited in relation to 42 CFR 416.51(b) and (b)(3). If training is completely absent, then consideration should be given to conditionlevel citation in relation to 42 CFR 416.51, particularly when the ASC’s practices fail to comply with infection control standards of practice.

20. How many procedures were

observed during the site visit?

1

2

3

4

Other

 

 

 

 

 

 

If other, please print the number:

procedures

5 of 15

PART 2 – INFECTION CONTROL & RELATED PRACTICES

INSTRUCTIONS:

Please completely fill in ONE bubble for each “Was Practice Performed?” and “Manner of Confirmation” question, unless otherwise noted.

Please use a dark pen to fully fill in each bubble.

Unless otherwise indicated, a “No” response to any question below must be cited as a deficient practice in relation to 42 CFR 416.51(a).

If N/A is response, please explain why there is no associated observation, or why the question is not applicable, in the COMMENTS box at the end of each section.

I.Hand Hygiene

Observations are to focus on staff directly involved in patient are (e.g., physicians, nurses, CRNAs, etc.).

Hand hygiene should be observed not only during the case being followed, but also while making other observations in the ASC throughout the survey. Interviews are used primarily to provide additional evidence for what the surveyor has observed, but may in some cases substitute for direct observation to support a citation of deficient practice.

Practices to be Assessed

Was Practice Manner of Performed? Confirmation

A. All patient care areas have:

Note: 42 CFR 416.51(a) should be cited only if the answer to both a and b is “No.”

 

Yes

Observation

a. Soap and water available

No

Interview

 

 

 

Both

 

 

 

 

 

b. Alcoholbased hand rubs available

Yes

Observation

No

Interview

 

 

 

Both

 

 

 

 

 

I. If alcoholbased hand rub is available in patient care areas, it is

Yes

 

 

installed as required. (There are LSC requirements at 42 CFR

No

 

 

416.44(b)(5) for installation of alcohol‐based hand rubs)

 

 

 

 

 

 

 

 

 

B. Staff perform hand hygiene:

 

 

 

 

 

Yes

Observation

a. After removing gloves

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

b. After direct patient contact

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

c. Before performing invasive procedures (e.g., placing an IV)

No

Interview

 

N/A

Both

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Practices to be Assessed

Was Practice

Manner of

 

Performed?

Confirmation

 

 

 

 

d. After contact with blood, body fluids, or contaminated surfaces

Yes

Observation

 

(even if gloves are worn)

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

C. Regarding gloves, staff:

 

 

 

 

 

a. Wear gloves for procedures that might involve contact with blood

Yes

Observation

 

or body fluids

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

b. Wear gloves when handling potentially contaminated patient

Yes

Observation

 

 

 

 

equipment

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

c. Remove gloves before moving to the next tasks and/or patient

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

D. Additional breaches in hand hygiene, not captured by the questions

Yes

Observation

 

 

 

 

above, were identified (If YES, please specify further in comments)

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

(please print and limit

 

 

 

 

 

 

comments to the space

 

 

 

 

 

 

provided)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II.Injection Practices (injectable medications, saline, other infusates)

Observations are to be made of staff who prepare and administer medications and perform injections (e.g., anesthesiologists, certified registered nurse anesthetists, nurses).

Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

Yes

Observation

A. Needles are used for only one patient

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

B. Syringes are used for only one patient

No

Interview

 

N/A

Both

 

 

 

 

 

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Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

Yes

Observation

C. Medication vials are always entered with a new needle

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

D. Medication vials are always entered with a new syringe

No

Interview

 

N/A

Both

 

 

 

 

 

E. Medications that are predrawn are labeled with the time of draw, initials

Yes

Observation

of the person drawing, medication name, strength and expiration date or

No

Interview

time

N/A

Both

Note: A “No” answer should result in citation as a deficient practice in relation to 42 CFR 416.48(a), Administration of Drugs

F.

a. Single dose (singleuse) medication vials are used for only one

Yes

Observation

 

patient

(A “No” response must be cited in relation to 42 CFR

 

No

Interview

 

416.48(a).)

 

N/A

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

b. Manufactured prefilled syringes are used for only one patient

No

Interview

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

c. Bags of IV solutions are used for only one patient

No

Interview

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

 

 

d. Medication administration tubing and connectors are used for

Yes

Observation

 

 

 

 

only one patient

No

Interview

 

 

 

 

 

 

 

 

N/A

Both

G. Please print all injectable medications/infusates that are in a vial/container used for more than one patient:

Name of Medication

Average number of patients per vial/container

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

H. Multidose injectable medications are used for only one patient

Yes

Observation

 

No

Interview

 

N/A

Both

(Note: a “No” answer here is not necessarily a breach in infection control and does not result in a citation. However, a “No” response to the related questions I K should be cited).

(Fill in N/A if no multidose medications/infusates are used).

If YES, please skip to “L”

If NO, please answer “I‐K”:

 

I. The rubber septum on a multidose vial used for more than one patient

Yes

Observation

 

is disinfected with alcohol prior to each entry

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

J. Multidose medications used for more than one patient are dated when

Yes

Observation

 

they are first opened and are discarded within 28 days of opening or

No

Interview

 

according to manufacturer’s recommendations, whichever comes first

N/A

Both

 

 

 

 

 

 

 

 

K. Multidose medications, used for more than one patient, are not stored

Yes

Observation

 

or accessed in the immediate areas where direct patient contact occurs

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

L. All sharps are disposed of in a punctureresistant sharps container

Yes

Observation

 

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

M. Sharps containers are replaced when the fill line is reached

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

N. Additional breaches in injection practices, not captured by the questions

Yes

Observation

 

above were identified (If YES, please specify further in comments)

No

Interview

 

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

(please print and limit

 

 

 

 

 

 

comments to the

 

 

 

 

 

 

space provided)

 

 

 

 

 

 

 

 

 

 

 

 

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III.Single Use Devices, Sterilization, and High Level Disinfection

Pre‐cleaning must always be performed prior to sterilization and highlevel disinfection

Sterilization must be performed for critical equipment (i.e., instruments and equipment that enter normally sterile tissue or the vascular system, such as surgical instruments)

High‐level disinfection must be performed for semicritical equipment (i.e., items that come into contact with nonintact skin or mucous membranes such as reusable flexible endoscopes, laryngoscope blades)

Observations are to be made of staff who perform equipment reprocessing (e.g., surgical techs), unless these activities are performed under contract or arrangement off‐site from the ASC.

SINGLE‐USE DEVICES

(Choose N/A if singleuse devices are never reprocessed and used again)

(Surveyor to confirm there is a contract or other documentation of an arrangement with a reprocessing facility by viewing it)

Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

 

 

 

 

 

 

A.

a. If singleuse devices are reprocessed, they are devices that are

Yes

Observation

 

approved by the FDA for reprocessing

No

Interview

 

 

N/A

Both

 

 

 

 

 

 

 

b. If singleuse devices are reprocessed, they are reprocessed by an

Yes

Observation

 

FDAapproved reprocessor.

No

Interview

 

 

N/A

Both

 

 

 

 

 

 

 

STERILIZATION

 

 

 

 

 

 

 

 

 

 

 

 

Yes

Observation

A. Critical equipment is sterilized

No

Interview

 

 

N/A

Both

 

 

 

 

 

B. Are sterilization procedures performed onsite?

Yes

Observation

(If NO, skip to “F”)

No

Interview

 

 

N/A

Both

(A “No” answer does not result in a citation, since ASCs are permitted to provide for sterilization offsite, under a contractual arrangement.)

(Surveyor to confirm there is a contract or other documentation of an arrangement for offsite sterilization by viewing it)

a. If YES to B, please indicate method of sterilization:

Steam autoclave

Peracetic acid

Other (please print):

C. Items are precleaned according to manufacturer’s instructions or

Yes

Observation

 

 

evidencebased guidelines prior to sterilization

No

Interview

 

N/A

Both

 

 

 

 

 

 

 

 

 

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Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

 

D.

Yes

Observation

 

a. Medical devices and instruments are visually inspected for residual

No

Interview

 

soil and recleaned as needed before packaging and sterilization

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

b. A chemical indicator is placed in each load

No

Interview

 

 

 

N/A

Both

 

 

 

Yes

Observation

 

c. A biologic indicator is performed at least weekly and with all

No

Interview

 

implantable loads

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

d. Each load is monitored with mechanical indicators (e.g. time,

No

Interview

 

temperature, pressure)

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

e. Documentation for each piece of sterilization equipment is

No

Interview

 

maintained and up to date and includes results from each load

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

E. Items are appropriately contained and handled during the sterilization

No

Interview

 

process to assure that sterility is not compromised prior to use

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

F. After sterilization, medical devices and instruments are stored in a

No

Interview

 

designated clean area so that sterility is not compromised

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

G. Sterile packages are inspected for integrity and compromised packages

No

Interview

 

are reprocessed

N/A

Both

 

 

 

 

 

 

 

 

 

 

Yes

Observation

 

H. Additional breaches in sterilization practices not captured by the

No

Interview

 

questions above were identified (If YES, please specify further in comments)

N/A

Both

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

(please print and limit

 

 

 

 

 

comments to the space

 

 

 

 

 

provided)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HIGH‐LEVEL DISINFECTION

 

 

 

 

 

 

 

 

 

 

 

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Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

A. Semicritical equipment is highlevel disinfected or sterilized

Yes

Observation

No

Interview

 

N/A

Both

 

 

 

 

 

B. Is highlevel disinfection performed on site?

Yes

Observation

 

 

(If NO, Skip to “F”)

No

Interview

 

 

 

N/A

Both

(A “No” answer does not result in a citation, since ASCs are permitted to provide for highlevel disinfection offsite, under a contractual arrangement.)

(Surveyor to confirm there is a contract or other documentation of an arrangement for offsite sterilization by viewing it)

a. If answer to B was YES, please indicate method of highlevel disinfection:

Manual

Automated

Other (please print):

C. Items are precleaned according to manufacturer’s instructions or

Yes

Observation

 

 

evidencebased guidelines prior to highlevel disinfection

No

Interview

 

 

N/A

Both

 

 

 

 

 

 

D.

a. Medical devices and instruments are visually inspected for

Yes

Observation

 

residual soil and recleaned as needed before highlevel

No

Interview

 

disinfection

N/A

Both

 

 

 

 

 

 

 

b. Highlevel disinfection equipment is maintained according to

Yes

Observation

 

 

 

 

manufacturer instructions

No

Interview

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

c. Chemicals used for highlevel disinfection are:

 

 

 

 

 

 

Yes

Observation

 

I. Prepared according to manufacturer instructions

No

Interview

 

 

N/A

Both

 

 

 

 

 

 

 

II. Tested for appropriate concentration according to

Yes

Observation

 

 

 

 

manufacturer’s instructions

No

Interview

 

 

 

 

 

N/A

Both

 

 

 

 

 

 

 

 

Yes

Observation

 

III. Replaced according to manufacturer’s instructions

No

Interview

 

 

N/A

Both

 

 

 

 

 

 

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Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

IV. Documented to have been prepared and replaced

Yes

Observation

 

 

according to manufacturer’s instructions

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

d. Instruments requiring highlevel disinfection are:

 

 

 

 

I. Disinfected for the appropriate length of time as specified

Yes

Observation

by manufacturer’s instructions or evidencebased guidelines

No

Interview

 

N/A

Both

 

 

 

 

 

II. Disinfected at the appropriate temperature as specified by

Yes

Observation

manufacturer’s instructions on evidencebased guidelines

No

Interview

 

N/A

Both

 

 

 

 

 

E. Items that undergo highlevel disinfection are allowed to dry before use

Yes

Observation

No

Interview

 

N/A

Both

 

 

 

 

 

F. Following highlevel disinfection, items are stored in a designated clean

Yes

Observation

area in a manner to prevent contamination

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

G. Additional breaches in highlevel disinfection practices, not captured by

Yes

Observation

the questions above were identified (If YES, please specify further in

No

Interview

comments)

N/A

Both

Comments:

(please print and limit comments to the space provided)

13 of 15

IV. Environmental Infection Control

Observations are to be made of staff who perform environmental cleaning (e.g., surgical technicians, cleaning staff, etc.)

Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

 

 

 

 

A. Operating rooms are cleaned and disinfected after each surgical or

Yes

Observation

 

 

invasive procedure with an EPAregistered disinfectant

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

B. Operating rooms are terminally cleaned daily

No

Interview

 

N/A

Both

 

 

 

 

 

C. Hightouch surfaces in patient care areas are cleaned and disinfected with

Yes

Observation

an EPAregistered disinfectant

No

Interview

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

D. The ASC has a procedure in place to decontaminate gross spills of blood

No

Interview

 

N/A

Both

 

 

 

 

 

E. Additional breaches in environmental cleaning not captured by the

Yes

Observation

 

 

questions above were identified (If YES, please specify further in comments)

No

Interview

 

N/A

Both

Comments:

(please print and limit comments to the space provided)

14 of 15

V.Point of Care Devices (e.g., blood glucose meter)

Observations are to be made of staff who perform fingerstick testing (e.g., nurses)

If N/A is filled in, please clarify why in the comments box below why it was not applicable or not observed.

Practices to be Assessed

Was Practice

Manner of

Performed?

Confirmation

 

 

 

 

 

 

1. Does the ASC have a blood glucose meter?

Yes

Observation

 

 

If NO, STOP HERE.

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

A. A new singleuse, autodisabling lancing device is used for each patient

Yes

Observation

No

Interview

 

N/A

Both

 

 

 

 

 

B. The glucose meter is not used on more than one patient unless the

Yes

Observation

 

 

manufacturer’s instructions indicate this is permissible

No

Interview

 

 

 

N/A

Both

 

 

 

 

 

 

Yes

Observation

C. The glucose meter is cleaned and disinfected after every use.

No

Interview

 

N/A

Both

 

 

 

 

 

D. Additional breaches in appropriate use of point of care devices (like

Yes

Observation

glucose meters) not captured by the questions above were identified

No

Interview

(If YES, please specify further in comments)

N/A

Both

Comments:

(please print and limit comments to the space provided)

15 of 15