Infection Prevention: Navigating CMS’s Infection Control Worksheet

Complying with these requirements should be a top priority for admins.

If you aren’t intimately familiar with the CMS Infection Control (IC) worksheet, you’ll probably want to make it a top priority — and the sooner, the better.

Used by facility leaders and surveyors alike, the IC worksheet is the basis for all compliance with the Infection Control Conditions for Coverage chapter of CMS’s State Operations Manual. (You can begin evaluating your program by accessing the worksheet here.)

The worksheet includes the required elements of an infection control program. If deficiencies are identified in any of the required elements, surveyors are required to cite those issues. The worksheet offers leaders a prime opportunity to look at their infection program through the eyes of a surveyor, assess potential deficiencies and implement changes.

Start here

The ASC Characteristics portion of the worksheet requests demographic, ownership, accreditation and services-provided information specific to your facility. Your infection control program will ultimately be evaluated by your responses, so make sure they are accurate.

The Infection Control Program portion of the worksheet assesses compliance with the specific requirements, and your answers may trigger an automatic cited deficiency. Preemptively addressing the requirements below will ensure you are compliant.

Requirement #1: The ASC must have an explicit infection control program that is based on nationally recognized guidelines.

Keys to compliance:

• CDC/HICPAC Guidelines: Guideline for Isolation Precautions
• Hand Hygiene (CDC/HICPAC); Disinfection and Sterilization in Healthcare Facilities (CDC/HICPAC); and Environmental Infection Control in Healthcare Facilities (CDC/HICPAC)
• Guidelines for Perioperative Practice (AORN)
• Guidelines issued by a specialty surgical society/organization

Requirement #2: The ASC must have a licensed healthcare professional qualified through training in infection control and designated to direct the ASC’s IC program.

Keys to compliance:

• Infection Prevention Certification is not required, but if not certified, the type of training the individual received must be documented.
• Indicate how many hours per week is spent on directing the IC program.

Requirement #3: The ASC must have a system to actively identify infections that may have been related to procedures performed at the ASC.

Keys to compliance:

• Indicate how the ASC obtains this information: ASC follows up with patients, primary care physician, or relies on the physician who performed the procedure to evaluate and report findings to the ASC.
• Supporting documentation will be requested to confirm the tracking activity.

Requirement #4: The ASC must have a policy/procedure in place to comply with state notifiable disease reporting requirements.

Key to compliance:

• Include the notifiable disease reporting requirements of your specific state in your Infection Control Program.

Requirement #5: The ASC must provide infection control training to members of the medical, nursing, and other staff providing care, as well as the cleaning staff and those responsible for sterilization and high-level disinfection.

Keys to compliance:

• Indicate the training method (in-service, computer based, etc.)
• Indicate which staff members received the training and if it is the same or different for all staff categories
• Indicate the frequency of the training (upon hire, annually, periodically/as needed, etc.)

Specific practices

Part 2 of the CMS Worksheet includes a section called Infection Control and Related Practices.Surveyors will attempt to observe the following practices in your facility:

• Hand hygiene
• Injection practices
• Single-use devices, sterilization and high-level disinfection
• Environmental infection control
• Point of care devices (e.g., blood glucose meter).

If you need more information on the requirements, AORN’s ASC Academy: Infection Prevention course explores the parameters of a successful IC program, follows the most updated CMS Surveyor Worksheet, and highlights important elements of compliance. Learn more about AORN’s infection prevention course and find other ambulatory education solutions at aorn.org/asc. OSM