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

Form Preview Example

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 on‐site 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. 10‐digit 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 CMS‐ recognized 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

1 of 15

8. What is the ownership of the

Physician‐owned

facility?

Hospital‐owned

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 of 15

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 condition‐level 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 condition‐level 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 condition‐level 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 condition‐level 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 on‐site

 

 

 

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 e‐mails to patients after discharge

obtain this information?

The ASC follows‐up 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 follow‐up 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.

4 of 15

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)

In‐service

Computer‐based 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 on‐site sterilization/high‐level 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 condition‐level 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

Infection Control Worksheet Form isn’t the one you’re looking for?

Related Documents