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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 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

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
		 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

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8. What is the ownership of the		Physician‐owned
facility?		Hospital‐owned
		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?

Number actively maintained:



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
		 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
		 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	 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.

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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)			 YES
	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
	17d. On average, how many hours per week
does this person spend in the ASC directing
the infection control program?
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)	
(Fill in ALL that apply)		discharge
		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
		 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
	19. Do staff members receive infection control training?	 NO
		 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
19c. Is training:
	 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

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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. Alcohol‐based hand rubs available		Yes		Observation
b. Alcohol‐based hand rubs available		No		Interview
				Both

I. If alcohol‐based 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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation
d. After contact with blood, body fluids, or contaminated surfaces		Yes		Observation
(even if gloves are worn)		No		Interview
(even if gloves are worn)			
		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
or body fluids			
		N/A		Both

b. Wear gloves when handling potentially contaminated patient		Yes		Observation
			
equipment		No		Interview
equipment			
		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
Practices to be Assessed	Performed?		Confirmation
	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
Practices to be Assessed	Performed?		Confirmation
	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 pre‐drawn 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 (single‐use) 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
	only one patient				
				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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation
H. Multi‐dose 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 multi‐dose medications/infusates are used).

If YES, please skip to “L”

If NO, please answer “I‐K”:

I. The rubber septum on a multi‐dose vial used for more than one patient		Yes		Observation
is disinfected with alcohol prior to each entry		No		Interview
is disinfected with alcohol prior to each entry			
		N/A		Both

J. Multi‐dose 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. Multi‐dose 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 puncture‐resistant 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 high‐level 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 semi‐critical equipment (i.e., items that come into contact with non‐intact 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 single‐use 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
Practices to be Assessed		Performed?		Confirmation
		Performed?		Confirmation

A.	a. If single‐use devices are reprocessed, they are devices that are		Yes		Observation
	approved by the FDA for reprocessing		No		Interview
			N/A		Both

	b. If single‐use devices are reprocessed, they are reprocessed by an		Yes		Observation
	FDA‐approved reprocessor.		No		Interview
			N/A		Both

	STERILIZATION

			Yes		Observation
A. Critical equipment is sterilized			No		Interview
			N/A		Both

B. Are sterilization procedures 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 sterilization off‐site, under a contractual arrangement.)

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

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

Steam autoclave

Peracetic acid

Other (please print):

C. Items are pre‐cleaned according to manufacturer’s instructions or		Yes		Observation
			
evidence‐based guidelines prior to sterilization		No		Interview
		N/A		Both

				10 of 15

Practices to be Assessed			Was Practice		Manner of
Practices to be Assessed			Performed?		Confirmation
			Performed?		Confirmation
D.				Yes		Observation
	a. Medical devices and instruments are visually inspected for residual			No		Interview
	soil and re‐cleaned 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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation
A. Semi‐critical equipment is high‐level disinfected or sterilized		Yes		Observation
		No		Interview
		N/A		Both

B. Is high‐level disinfection performed on site?		Yes		Observation
B. Is high‐level disinfection performed on site?			
(If NO, Skip to “F”)		No		Interview
(If NO, Skip to “F”)			
		N/A		Both

(A “No” answer does not result in a citation, since ASCs are permitted to provide for high‐level disinfection off‐ site, under a contractual arrangement.)

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

a. If answer to B was YES, please indicate method of high‐level disinfection:

Manual

Automated

Other (please print):

C. Items are pre‐cleaned according to manufacturer’s instructions or			Yes		Observation
				
evidence‐based guidelines prior to high‐level disinfection			No		Interview
			N/A		Both

D.	a. Medical devices and instruments are visually inspected for		Yes		Observation
	residual soil and re‐cleaned as needed before high‐level		No		Interview
	disinfection		N/A		Both

	b. High‐level disinfection equipment is maintained according to		Yes		Observation
				
	manufacturer instructions		No		Interview
	manufacturer instructions			
			N/A		Both

	c. Chemicals used for high‐level disinfection are:
			Yes		Observation
	I. Prepared according to manufacturer instructions		No		Interview
			N/A		Both

	II. Tested for appropriate concentration according to		Yes		Observation
	II. Tested for appropriate concentration according to			
	manufacturer’s instructions		No		Interview
	manufacturer’s instructions			
			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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation
IV. Documented to have been prepared and replaced		Yes		Observation
IV. Documented to have been prepared and replaced			
according to manufacturer’s instructions		No		Interview
according to manufacturer’s instructions			
		N/A		Both

d. Instruments requiring high‐level disinfection are:
I. Disinfected for the appropriate length of time as specified		Yes		Observation
by manufacturer’s instructions or evidence‐based guidelines		No		Interview
		N/A		Both

II. Disinfected at the appropriate temperature as specified by		Yes		Observation
manufacturer’s instructions on evidence‐based guidelines		No		Interview
		N/A		Both

E. Items that undergo high‐level disinfection are allowed to dry before use		Yes		Observation
		No		Interview
		N/A		Both

F. Following high‐level disinfection, items are stored in a designated clean		Yes		Observation
area in a manner to prevent contamination		No		Interview
area in a manner to prevent contamination			
		N/A		Both

G. Additional breaches in high‐level 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)

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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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation

A. Operating rooms are cleaned and disinfected after each surgical or		Yes		Observation
			
invasive procedure with an EPA‐registered disinfectant		No		Interview
		N/A		Both

		Yes		Observation
B. Operating rooms are terminally cleaned daily		No		Interview
		N/A		Both

C. High‐touch surfaces in patient care areas are cleaned and disinfected with		Yes		Observation
an EPA‐registered 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)

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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
Practices to be Assessed	Performed?		Confirmation
	Performed?		Confirmation

1. Does the ASC have a blood glucose meter?		Yes		Observation
1. Does the ASC have a blood glucose meter?			
If NO, STOP HERE.		No		Interview
If NO, STOP HERE.			
		N/A		Both

A. A new single‐use, auto‐disabling 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
manufacturer’s instructions indicate this is permissible			
		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

Question	Answer
Form Name	Infection Control Worksheet Form
Form Length	15 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 45 sec
Other names	infection surveyor, hospital infection control survyor worksheet, infection control worksheet, cms cop infection control worksheet

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